Managed Care Compliance AND Audit Coordinator

The Managed Care Compliance and Audit Coordinator (CA Coordinator) works closely with the Managed Care Compliance and Audit Manager to assist with compliance and auditing functions of NEMS MSO (Management Services Organization), including, but not limited to, internal and external audit activities of claims processing and adjudication, Utilization Management, Credentialing, Case Management, and quality improvement initiatives. This role will also be responsible for monitoring regulatory requirements, understanding how requirements impact MSO operations, and assist with providing guidance to relevant teams.

ESSENTIAL JOB FUNCTIONS:

• Conduct internal audits to systematically assess the department's risks and efficacy of delegated functions and activities, policies, and procedures, using assessment and auditing tools approved by contracted health plan and/or developed internally.
• Coordinate inter-department and cross-department level projects including planning, workgroup meetings, collecting and setting agenda items, creating meeting minutes, and following up with action items.
• Assist with administrative tasks from the MSO Compliance and Audits (C&A). The C&A Team and other MSO units work collaboratively to promote quality assurance and quality improvement activities.
• Collaborate with different MSO units, including Claims, UM, Provider Relations, Care Management, and Data Reporting, to relay compliance requirements, audit scores, corrective action plans, and to ensure non-compliance area(s) is corrected and monitored.
• Work closely with MSO C&A manager, department managers, and external health plan auditors with compliance audit activities, including but not limited to internal and external of communication about audit calendar/schedule and level of requirement, report submission, gathering of documents, etc., to facilitate a smooth and positive audit experience from external auditors.
• Analyze regulatory guidance documents, document requirements, understand & communicate requirements, and collaborate with different teams to monitor compliance.
• Analyze reports and present findings to the C&A team and different MSO units.
• Collaborate with different teams and departments to ensure compliance with NCQA standards to maintain NEMS's NCQA accreditations.
• Performs other job duties as required by manager/supervisor.