Customer Solution Center Appeal and Grievance Compliance Advisor

$88,854 - $115,509 yearly
  • The Resume Review - Recruiting Department
  • Hybrid (Los Angeles, CA, USA)
  • May 23, 2024
Full time Health Care

Job Description

Job description
Job Summary

The Customer Solution Center Audit Readiness Specialist II is responsible for the execution, oversight, and monitoring of the guidelines and protocols to ensure readiness for all regulatory audits. This position will develop, with the assistance of CSC management, a successful auditing strategy for the following end-to-end processes within CSC (i.e. Enrollment processing timeliness and accuracy of loading members, timeliness of I.D. Card and member materials, outbound health risk assessment (HRA) calls for Seniors and People with Disabilities (SPD) and Cal MediConnect (CMC) plus HIF for OUR Medi-Cal Direct program (MCLA), call documentation and categorization, service authorization request and coverage determination , Appeals and Grievances across all lines of business). This position is responsible for the ongoing progression and maintenance of CSC's compliance program efforts, including, but not limited to, policy and procedure development, training and education initiatives, and compliance programmatic developments and enhancements.


This position will complete targeted, focused and random audits related to member interactions and outcomes to ensure all elements are compliant. These results will be provided to management with recommendations and/or corrective actions required to remediate the deficiencies. This position will be responsible for the regulatory obligations for each line of business and their governing bodies; California Department of Health Care Services (DHCS), Department of Public Social Services (DPSS), Centers for Medicare and Medicaid Services(CMS), LACC - CalHers, and National Committee for Quality Assurance (NCQA) along with review and analysis of regulatory requirements for all product lines The position will take lead in all of the audit situations and be prepared to present and report full findings and ensure action plans are created, executed, and verified through reconciliation of end to end on all regulatory functions.   


Audit readiness:

Performs audit procedures for Customer Solution Center departments to ensure readiness; including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting business unit processes and procedures. Conducts interviews, reviews documents, develops and administers surveys, composes summary memos and prepares working papers. Identifies, develops, and documents audit issues and recommendations using independent judgement concerning areas being reviewed. Communicates or assists in communicating the results of audit and consulting projects via written reports and oral presentations to Customer Solution Center management. Collaborates with business units in audit universe preparation and validation. Assists in document preparation for regulatory and internal audits.

Regulatory compliance:

Works closely with Customer Solution Center Management to determine and handle effectiveness/accuracy of operational processes. Collaborates with internal SMEs to understand Customer Solution Center regulatory processes and assists with getting to the root cause of identified deficiencies. Evaluates policies and procedures with applicable regulations/guidelines and provides recommendations to management for continuous process improvements.        


Collaborates with Customer Solution Center Business Analyst to track, trend, and analyze results of QA scorecards for training and quality improvement.