Solugenix Corporation
Senior Health Plan Auditor
Solugenix Corporation, Los Angeles, California, United States, 90079
Senior Health Plan Auditor
Los Angeles, CA (Remote)
4+ Month Contract (Possibility of Conversion)
Job ID 25-09680
Solugenix is assisting a client, a health insurance company, in their search for a
Senior Health Plan Auditor.
This is a 4+ month contract opportunity based out of Los Angeles, CA (Remote).
The Senior Health Plan Auditor is a remote role and is responsible for all aspects of planning, execution, reporting and corrective action plan monitoring of financial solvency and claims processing compliance for specialty health plans and vendors. These audits are intended to ensure that the client delegates are in compliance with regulatory requirements and the client's contractual agreements across all lines of business.
The position is responsible for the DMHC claims data submissions for the client and its Plan Partners and delegates done each quarter and annually. Primarily responsible for the creation, review, and submission of departmental policies and procedures annually. Serves as a subject matter expert and mentor for other staff.
Qualifications: Education Required: Bachelor's Degree in Accounting or Related Field. In lieu of a degree, equivalent education and/or experience may be considered. Experience Required:
t least 3 years of experience in conducting financial audits. t least 5 years of related experience in the managed healthcare industry. Minimum of 2 years of accounting experience. Skills Required:
Strong analytical and critical thinking skills. ction-oriented, self-starter, and an excellent motivator. Excellent verbal and written communication skills. ble to prioritize assignments, and able to independently with minimum supervision. bility to interface professionally with both internal and external customers at all levels of the organization. Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint). Must have Managed care, health care, insurance background financial audit/analyst experience. Must have any of the following certifications: CMA OR CIA OR CPA OR CFE OR CISA. Supporting the Financial audit/Claims Audit, Financial Solvency operations. Support State Compliance Filing, AB1455. Responsibilities:
Performs financial audits and/or financial analyses for Specialty Health Plans. Performs financial analyses or vendor management for the client vendors. Performance claims audits for Specialty Health Plans and vendors. Provides timely and accurate deliverables to ensure financial solvency and claims processing compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors. ssists in the creation and implementation of standardized Specialty Health Plans and vendors workpaper and reporting templates. Responsible for the documentation and maintenance of the Financial Compliance Department's policies and procedures. Responsible for collection and completion of the quarterly and annual Department of Managed Health Care (DMHC) filing submissions. Being cross trained on financial solvency reviews for PPGs, PPs, and capitated hospitals. Serves as primary contact and liaison for the Centers for Medicare and Medicaid Services (CMS) claim audit section of the client delegates. nnually reviews and updates the department's Policies and Procedures (P&Ps). Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission. ccountable for the completion of requests from the Legal Department, Delegation Oversight's monitoring oversight and reporting. Serves as subject matter expert in assigned areas and cross-training initiatives. Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors. Supports the design, implementation, and reporting of special projects. Supports the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications. Supports the assessment, communication, and implementation of regulatory requirements that may impact internal processes. Supports the formalization of key internal processes and monitoring tools with desktop procedures and applicable policies and procedures development. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Provides training, recommend process improvements, and mentor junior-level staff, department interns, etc. as needed. Performs other duties as assigned. Licenses/Certifications (Must hold one of the below certifications):
Certified Public Accountant (CPA) Certified Management Accountant (CMA) Certified Internal Auditor (CIA) Certified Fraud Examiner (CFE) Candidates must understand financial statements:
Financial statement analysis & conduct risk assessment and communicate with (PPGs) Plan partners as needed. Risk Assessment -
Recognize trends in industry Conduct Audits, identify areas of issues CAPS with providers as needed (corrective action plans) Cost Analysis Root cost analysis Medicaid/Medicare Auditing - a huge plus
Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $55/hour to $57/hour. Starting rate of pay offered may vary depending on factors including but not limited to, position offered, location, education, training and/or experience.
Solugenix will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act and Ordinance. Applicants do not need to disclose their criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if we are concerned about conviction that is directly related to the job, applicants will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.
bout the Client Our client is one of the world's leading health insurance companies based out of Los Angeles, CA.
bout Solugenix Solugenix is a leader in IT services, delivering cutting-edge technology solutions, exceptional talent, and managed services to global enterprises. With extensive expertise in highly regulated and complex industries, we are a trusted partner for integrating advanced technologies with streamlined processes. Our solutions drive growth, foster innovation, and ensure compliance-providing clients with reliability and a strong competitive edge. Recognized as a 2024 Top Workplace, Solugenix is proud of its inclusive culture and unwavering commitment to excellence. Our recent expansion, with new offices in the Dominican Republic, Jakarta, and the Philippines, underscores our growing global presence and ability to offer world-class technology solutions. Partnering with Solugenix means more than just business-it means having a dedicated ally focused on your success in today's fast-evolving digital world.
Solugenix is assisting a client, a health insurance company, in their search for a
Senior Health Plan Auditor.
This is a 4+ month contract opportunity based out of Los Angeles, CA (Remote).
The Senior Health Plan Auditor is a remote role and is responsible for all aspects of planning, execution, reporting and corrective action plan monitoring of financial solvency and claims processing compliance for specialty health plans and vendors. These audits are intended to ensure that the client delegates are in compliance with regulatory requirements and the client's contractual agreements across all lines of business.
The position is responsible for the DMHC claims data submissions for the client and its Plan Partners and delegates done each quarter and annually. Primarily responsible for the creation, review, and submission of departmental policies and procedures annually. Serves as a subject matter expert and mentor for other staff.
Qualifications: Education Required: Bachelor's Degree in Accounting or Related Field. In lieu of a degree, equivalent education and/or experience may be considered. Experience Required:
t least 3 years of experience in conducting financial audits. t least 5 years of related experience in the managed healthcare industry. Minimum of 2 years of accounting experience. Skills Required:
Strong analytical and critical thinking skills. ction-oriented, self-starter, and an excellent motivator. Excellent verbal and written communication skills. ble to prioritize assignments, and able to independently with minimum supervision. bility to interface professionally with both internal and external customers at all levels of the organization. Proficiency in Microsoft Office (Excel, PowerPoint, and SharePoint). Must have Managed care, health care, insurance background financial audit/analyst experience. Must have any of the following certifications: CMA OR CIA OR CPA OR CFE OR CISA. Supporting the Financial audit/Claims Audit, Financial Solvency operations. Support State Compliance Filing, AB1455. Responsibilities:
Performs financial audits and/or financial analyses for Specialty Health Plans. Performs financial analyses or vendor management for the client vendors. Performance claims audits for Specialty Health Plans and vendors. Provides timely and accurate deliverables to ensure financial solvency and claims processing compliance with regulatory and contractual requirements for plan partners, participating provider groups, capitated hospitals, specialty health plans, and vendors. ssists in the creation and implementation of standardized Specialty Health Plans and vendors workpaper and reporting templates. Responsible for the documentation and maintenance of the Financial Compliance Department's policies and procedures. Responsible for collection and completion of the quarterly and annual Department of Managed Health Care (DMHC) filing submissions. Being cross trained on financial solvency reviews for PPGs, PPs, and capitated hospitals. Serves as primary contact and liaison for the Centers for Medicare and Medicaid Services (CMS) claim audit section of the client delegates. nnually reviews and updates the department's Policies and Procedures (P&Ps). Ensures that any new or updated Policy and Procedure is reviewed and approved by management prior to submission. ccountable for the completion of requests from the Legal Department, Delegation Oversight's monitoring oversight and reporting. Serves as subject matter expert in assigned areas and cross-training initiatives. Responsible for the overall communication and collaboration with interdepartmental personnel, leadership, specialty health plans, and vendors. Supports the design, implementation, and reporting of special projects. Supports the design and implementation of reports and tools for corrective action plan issuance and non-compliance notifications. Supports the assessment, communication, and implementation of regulatory requirements that may impact internal processes. Supports the formalization of key internal processes and monitoring tools with desktop procedures and applicable policies and procedures development. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Provides training, recommend process improvements, and mentor junior-level staff, department interns, etc. as needed. Performs other duties as assigned. Licenses/Certifications (Must hold one of the below certifications):
Certified Public Accountant (CPA) Certified Management Accountant (CMA) Certified Internal Auditor (CIA) Certified Fraud Examiner (CFE) Candidates must understand financial statements:
Financial statement analysis & conduct risk assessment and communicate with (PPGs) Plan partners as needed. Risk Assessment -
Recognize trends in industry Conduct Audits, identify areas of issues CAPS with providers as needed (corrective action plans) Cost Analysis Root cost analysis Medicaid/Medicare Auditing - a huge plus
Pay Range for CA, CO, IL, NJ, NY, WA, and DC: $55/hour to $57/hour. Starting rate of pay offered may vary depending on factors including but not limited to, position offered, location, education, training and/or experience.
Solugenix will consider qualified applicants with a criminal history pursuant to the California Fair Chance Act and Ordinance. Applicants do not need to disclose their criminal history or participate in a background check until a conditional job offer is made to you. After making a conditional offer and running a background check, if we are concerned about conviction that is directly related to the job, applicants will be given the chance to explain the circumstances surrounding the conviction, provide mitigating evidence, or challenge the accuracy of the background report.
bout the Client Our client is one of the world's leading health insurance companies based out of Los Angeles, CA.
bout Solugenix Solugenix is a leader in IT services, delivering cutting-edge technology solutions, exceptional talent, and managed services to global enterprises. With extensive expertise in highly regulated and complex industries, we are a trusted partner for integrating advanced technologies with streamlined processes. Our solutions drive growth, foster innovation, and ensure compliance-providing clients with reliability and a strong competitive edge. Recognized as a 2024 Top Workplace, Solugenix is proud of its inclusive culture and unwavering commitment to excellence. Our recent expansion, with new offices in the Dominican Republic, Jakarta, and the Philippines, underscores our growing global presence and ability to offer world-class technology solutions. Partnering with Solugenix means more than just business-it means having a dedicated ally focused on your success in today's fast-evolving digital world.