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Cedars-Sinai Managed Care Compliance Specialist - Managed Care in Los Angeles, California

The Managed Care Compliance specialist is responsible for assisting with the implementation of the internal auditing & monitoring program within the Managed Care department by ensuring compliance with applicable rules and regulations including but not limited to AB1455 and Medicare Claims Processing Guidelines. This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHCS.

Job Duties and Responsibilities:

  • Ensures all services provided to Commercial, Medicare and Medi-cal managed care members are in compliance with program regulations, insurance regulations, and regulatory requirements.

  • Maintains and supervise laws and regulations, contract documentations, amendments, and various compliance measures pertaining to Commercial, Medicare and Medi-cal managed care.

  • Develops policies, procedures, and processes to follow federal program regulations and any applicable state regulations pertaining to Commercial, Medicare and Medi-Cal managed care.

  • Provides mentorship to various departments regarding compliance issues and implementation of new compliance requirements with respect to regulatory and contract language for Commercial, Medicare and Medi-Cal managed care.

  • Acts as a liaison with health plans and current CSHS departments to ensure both health plan regulations and CSHS policies are met.

  • Coordinates and act as primary contact for all health plans audits, including being responsible for the review for performance management and accurate coding.

  • Develops and supervise compliance with corrective action plans as a result of post-health plan audits and regulatory audits.

  • Provides required Compliance and FWA trainings for existing and new employees and, as the need arises, non-employees.

  • Educates CSHS employees on company policies and procedures regarding access to care, the grievance and appeals process, the eligibility process, etc.

  • Remains updated on all member and provider policy changes made by the health plan and/or the State.

  • Acts as subject matter authority on health care laws/regulations as a compliance resource to CSHS and affiliates, including contracted and employed physician practices.

  • Aggregates, analyze, and report audit results, identify error trends and root causes, and make recommendations for performance improvements.

Education:

High school diploma/GED required. Bachelor's Degree in Healthcare or related field preferred.

Experience:

Two (2) years of Medi-Cal, Medicare or Commercial Managed Care experience required.

Five (5) years of compliance experience, preferably in a healthcare environment.

Working Title: Managed Care Compliance Specialist - Managed Care

Department: MNS - Managed Care

Business Entity: Medical Network

Job Category: ,Strategic Plan/Business Dev,Strategic Plan/Business Dev

Job Specialty: Managed Care

Position Type: Full-time

Shift Length: 8 hour shift

Shift Type: Day

Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.

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