- March 12, 2017
- Triple-S Salud
Executes activities related to the identification, monitoring and validation of correction for the compliance issues resulting from internal and/or external PSG, Commercial and or MA oversight activities. Comply with the regulatory agencies requirements and timeframes.
Plan and develop the audit approach for assigned projects consistent with ASES, CMS state guidelines, DOL, PSG, Commercial and or MA policies and procedures and in accordance with the timeframes established by the Compliance Audit Manager; Conduct robust pre-delegation audits for PSG ,Commercial and or MA lines of businesses in coordination with the contract administrators; Develop request for corrective action plans, root cause analysis and business impact analysis, either as a result of an internal or external audit or monitoring activities or as requested by a PSG, Commercial and or MA lines of businesses regulatory agency; Track PSG, Commercial and or MA lines of businesses open audit and monitoring issues and perform follow up to evaluate timeliness and adequacy of remediation efforts; Monitor the appropriate identification and correction of PSG, Commercial and or MA lines of businesses non-compliance instances and root causes; Provide compliance performance feedback to internal business units and delegated entities under the PSG, Commercial and or MA lines of businesses; Produce high quality audit and monitoring reports for Management and Delegated Entities, in compliance with PSG and Commercial lines of businesses policies and procedures; and in compliance with CMS regulatory requirements described in the Medicare Compliance Program Guidelines, Chapter 21 of the Medicare Managed Care manual and the Chapter 9 of the Medicare Prescription Drug Benefit manual and MA Line of Business policies and procedures. Monitor the MA, PSG and Commercial lines of businesses Compliance Company-wide monitoring tool, including but not limited to Compliance Dashboard or Compliance Scorecard; Support the MA, PSG and Commercial lines of businesses Compliance Delegation Oversight Program, including supporting the execution of periodic meetings with Delegated Entities and communication protocols; Conduct review of information provided by MA, PSG and Commercial lines of businesses internal departments and delegated entities for regulatory agencies oversight activities. Ensures the information is in compliance with the regulatory agencies requirements, identify and communicate to the Compliance Audit and Monitoring Manager and/or the Compliance Officer any associated risk; Responsible to manage, validate and submit MA Line of Business regulatory reporting requirements. Support and execute the communication, coordination, validation and submission of information regarding MA, PSG and Commercial lines of businesses Regulatory Agencies Oversight Activities; Develop and maintain effective senior line management and Delegated Entities relationship, and has a strong understanding of the MA, PSG and Commercial lines of businesses operations; Distribute tasks to the Organization through Compliance 360, and follow up on action items related to the MA, PSG and Commercial lines of businesses; Stay current in knowledge of industry trends, including but not limited to CMS, ASES, OCI, DOL and BCBS requirements; Contributes in the reduction of year to year compliance issues related to the MA, PSG and Commercial lines of businesses; Communicate on a timely manner the identified non-compliance issues to the Compliance Audit and Monitoring Manager and the Compliance Officer related to the MA, PSG and Commercial lines of businesses; Perform other related tasks as requested by supervisor or to cover absence of other staff employees assigned to the MA,PSG and Commercial lines of businesses; Other responsibilities according with the position and/or supervisor.
Bachelor Degree, preferable in Arts, Science or Business Administration with 1 to 3 years of related experience in audit, preferable in Medicare Advantage, Commercial Line or PSG. Or Associates Degree preferable in Arts, Science or in Business Administration with 3 to 5 years of related experience in audit, preferable in Medicare Advantage, Commercial Lines or PSG. Or at least 5 years of this experience in lieu of.
Read and correctly interpret government regulations and legal documents. Attention to detail and follow-up skills. Excellent research skills All employees are expected to support actively the metrics / indicators that will facilitate the accomplishment of the corporate and departmental objectives. In any opportunity during the performance of the tasks, the employee should: Maintain the minimum professional criterion of the job, complete all required trainings, and show commitment with compliance of Company’s policies and procedures. Treat all people with respect, assuring to provide an excellent service to our policyholders, participants, providers and clients, as well as with any employee or supervisor. Maintain composure in highly stressful or adverse situations. Maintain confidential the protected information which might have access as part of the job.