Network Compliance Auditor, FSR – RN

🔥 5 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $38 - $55 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔎 Auditor

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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SCAN

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1977

🏥 Healthcare

⚕️ Healthcare Insurance

👥 B2C

Healthcare • Healthcare Insurance • B2C

SCAN is a mission-driven healthcare organization focused on reinventing aging by delivering evidence-based, patient-centered care and coverage for older adults. It operates an integrated portfolio including health insurance plans with innovative benefits, in-home and virtual primary care, support programs for caregivers and homebound older adults, and specialized services for vulnerable populations. SCAN also invests in and partners with companies that advance care models and resources to help older adults remain healthy and independent at home.

📋 Description

• Perform and provide oversight for the Managed Care Plan’s DHCS auditing team • Conduct and oversee initial and subsequent reviews of Primary Care Provider sites, including Facility Site Reviews and Medical Record Reviews • Complete monthly audit assignments within established timelines with thorough, compliant documentation • Review, analyze, and interpret DHCS All Plan Letters, legislative, statutory, regulatory, and contract language • Develop implementation and communication plans for regulatory compliance and provider data requirements • Audit SCAN-contracted and collaborative PCP offices serving Medi-Medi members under CMS, DHCS, and contractual requirements • Provide auditing and post-audit documentation training, feedback, and improvement recommendations • Conduct closing meetings and provide preliminary overviews of compliance audit results • Support providers with corrective action plans, CAP monitoring, education, and compliance tools • Respond to provider disagreements with audit findings and analyze submitted reports and correction requests • Explain regulation interpretations and their application • Conduct annual oversight projects, correspondence, project coordination, delegated compliance monitoring, status reporting, and regulatory update coordination • Represent the Delegation Oversight Unit as a service delivery compliance subject matter expert • Partner with Compliance on SCAN policies related to NCQA, DHCS, CMS, and other regulatory revisions • Escalate longstanding non-compliance issues and identify barriers for supervisors/managers • Educate providers on delegated claims processing and denial of claims involving member liability • Review delegated administrator letters, Compliance Program processes, and data submissions for accuracy and compliance • Maintain member privacy and confidential information • Adhere to quality, compliance, and regulatory standards • Support SCAN’s vision and goals and perform other duties as assigned

🎯 Requirements

• Registered Nurse License (RN) required (current and active California license in good standing) • 2+ years clinical experience, including but not limited to ER/Acute Care nursing • Associate's Degree in Nursing • DHCS-CSR (certified site reviewer) preferred • Prior auditing experience preferred • Ability to work independently and in a team environment • Beginning to working knowledge of the subject matter • Basic technical skills for the functional area • Basic problem-solving skills • Good communication and interpersonal skills • Analytical, critical thinking, problem-solving, and decision-making skills • Strong attention to detail and organizational skills • Ability to prioritize multiple and competing tasks in a fast-paced environment • Proficient in MS Office and data entry • Valid driver’s license, automobile insurance, and reliable transportation • Ability to drive in assigned territory and flex to other areas as assigned • Background check required

🏖️ Benefits

• An annual employee bonus program • Robust Wellness Program • Generous paid-time-off (PTO) • 11 paid holidays per year • 1 floating holiday • Birthday off • 2 volunteer days • Excellent 401(k) Retirement Saving Plan with employer match • Robust employee recognition program • Tuition reimbursement • Equal pay and inclusive benefits • Opportunity to become part of a team that makes a difference to members and the community