Internal Auditor - CareConnect

Plans, designs, executes and reports audits tosupport CareConnect's operational, compliance/regulatory and risk managementobjectives. Audits encompass core operational processes including but notlimited to claims processing, enrollment, coverage determinations, utilizationmanagement, network management, credentialing, marketing, compliance program,grievances and appeals.
1. Assistsin conducting risk assessments and developing annual audit work plans, incoordination with Compliance, to support operational, compliance/regulatory andrisk management objectives for all lines of business.
2. Executesaudits and compliance reviews encompassing core operational processes includingbut not limited to; claims processing, enrollment, coverage determinations,utilization/care management, credentialing, marketing, compliance program, grievancesand appeals.
3. Developsaudit reports concerning findings and corrective actions required forpresentation to leadership including the ComplianceCommittee.
4. Monitorscorrective actions required by business owners through design, implementation,and completion.
5. Assists in coordinating with alloperational areas in preparing for and managing external regulatory audits orsite visits, i.e., CMS, DOH, DFS, OMIG, OIG, etc.
6. Participates in internal monitoringactivities and oversight of delegated entities to ensure compliance withregulators.
7. Assessescompliance to contract terms with the regulator (including Fully IntegratedDuals Advantage (FIDA) contract, MLTC contract and commercial business contract).
8. Supportsthe development of policies and procedures for all lines of business.
9. Assists in various compliance/regulatorydepartmental projects, as required, including fraud investigations.
10. Performs relatedduties, as required.
ADA Essential Functions
Bachelor'sDegree in Business Administration, HealthcareAdministration or related field, required.
CertifiedPublic Accountant or Certified Internal Auditor, required.
Minimum of five (5) years relatedexperience to include MedicareAdvantage, Managed Long-Term Care, Qualified Health Plan/NYS Health PlanMarketplace and/or other health care audit experience, required.
Fraudand other compliance-related investigation experience, preferred.
Excellentverbal and written communication skills, in documenting and summarizing auditfindings as well as in communicating with regulators and all levels ofleadership.

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