Medicare Part D Compliance Auditor

To change the future of health care in California, Blue Shield needs people who believe in the possibilities and are willing to work to make them real. Is this you?

Auditor to maintain Part D Audit Workplan in compliance with CMS guidance on Fraud, Waste and Abuse requirements to integrate relevant Part D contributing audit activity from internal audit, pharmacy services audits, department audits, Arugs audits, and special investigations. (Will also coordinate with outside firm if we elect to integrate outside pharmacy level auditing as future enhancement to audit scope). Auditor responsible to do audit validations for various activities that such as the COB information, TrOOP, Membership reconciliation, handling of expedited requests, etc. Work with Part D Compliance Officer as issues are identified to build in new key indicators for compliance committee reporting and for integration into the training workplan. If not duplicative of Pharmacy Services activity, suggest auditor role also include mail in auditing such as validation of specific pharmacy policies, review of sample pharmacy records to validate compliance controls with issues identified by CMS, US Attorney's office or OIG. Auditor would work with Special Investigations to hand off suspected fraud issues.

Requires Working independently, reviewing relevant regulatory guidance and delopment of work plan in conjunction with intenral departmetns and contractors. Conducts audits of various areas according to CMS gudlines.

Performs periodic audits of reporting and pharmacy infmation for accuracy/appropriateness of compliane with CMS guidelines.

Assists Part D Compliance Officer in developing compliance audit instruments and protocols. Revises policies and procedures to comply with regulatory changes.

Prepares analyses/reports based on audit results, including recommendations for corrective action. Maintains audit records.

Works with other departments (e.g., medical management) to coordinate audit activities.

Need a detail oriented individual who is self motivated and able to adapt to constant change in regulatory guidelines.

Strong team spirit and ability to work with others in achieving challenging goals while maintaining ease of businss approach.

Blue Shield of California is an Equal Opportunity Employer.

Bachelor's degree and three years related experience or equivalent combination of education and experience.

Broad knowledge of HMO policies and procedures and medicare benefits.

Experience in audit techniques, as well as ability to use audit results to make corrective action recommendations.

Working knowledge of computers and related software applications.

Good analytical skills.

Good oral and written communications skills; good organization and follow-up skills.

Willingness and ability to travel frequently to audit sites as needed.

Broad knowledge of applicable legislation/regulations and actively maintains compliance.