Health Plan Compliance Auditor

Health Plan Compliance Auditor

At CVS Health, we are building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation's leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Role description : The Health Plan Compliance Auditor supports compliance activities for Oak Street Health's internal care management and utilization management teams. They partner with operational leadership to implement and monitor ongoing quality improvement activities, lead external compliance and accreditation survey processes, and leverage program knowledge and analytical skills to effectively coordinate all compliance activities.

Responsibilities :

Possesses and demonstrates knowledge of CMS, contractual, accreditation, federal, state, and business requirements for assigned programs, and ensures compliance with program requirements

Collaborates with leadership to develop, implement, and maintain policies and procedures for assigned programs

Collaborates with leadership to develop and execute auditing and monitoring tools utilized for staff and program audits

Collaborates with payers, serves as SME for compliance-related activities

Contributes to reports used by internal and external leadership

Provides input and valuable feedback on auditing results, trends and improvement activities

Recommends process improvement, interventions, and assists with implementation

Develops and revises training materials based on QA results

Analyzes processes and key performance indicators to assess compliance risk, internal control, and overall effectiveness and efficiency

Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practices

Develops Corrective Action Plans (CAPs) and Performance Improvement Plans (PIPs) and is accountable for the adequacy of operational responses and ongoing monitoring

Performs other job duties, as assigned.

What we're looking for :

Bachelor's degree in Healthcare Administration, Compliance, related field, or equivalent experience

1-2 years of compliance experience dealing with care management requirements, utilization management requirements, auditing, reporting processes, action plans, and compliance training preferred

Strong understanding of healthcare laws, NCQA requirements, and Medicare Part C regulatory compliance in a managed care organization or hospital health care system setting

Experience working with regulators on compliance audits

Ability to work independently and with others

Experience in building and supporting strong teamwork and collaborative communication

Ability to work under pressure with multiple deadlines and priorities

Strong problem-solving skills, critical thinking skills, and organizational skills

US work authorization

Someone who embodies "Being Oaky"

What does being Oaky look like?

Radiating positive energy

Assuming good intentions

Creating an unmatched patient experience

Driving clinical excellence

Taking ownership and delivering results

Being relentlessly determined

Why Oak Street Health?

Oak Street Health is on a mission to rebuild healthcare as it should be, providing personalized primary care for older adults on Medicare, with the goal of keeping patients healthy and living life to the fullest. Our innovative care model is centered right in our patient communities, and focused on the quality of care over volume of services. We are an organization on the move! With over 200+ locations and an ambitious growth trajectory, Oak Street Health is attracting and cultivating team members who embody Oaky values and passion for our mission.

Benefits :

Mission-focused career impacting change and measurably improving health outcomes for Medicare patients

Paid vacation, sick time, and 401K match options

Health insurance, vision, and dental benefits

Opportunities for leadership development and continuing education stipends

New centers and flexible work environments

Opportunities for high levels of responsibility and rapid advancement

Oak Street Health is an equal opportunity employer. We embrace diversity and encourage all interested readers to apply.

Anticipated Weekly Hours : 40

Time Type : Full time

Pay Range : The typical pay range for this role is : $43,888.00 - $93,574.00

Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong.

Great benefits for great people

We take pride in our comprehensive and competitive mix of pay and benefits investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include :

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

We anticipate the application window for this opening will close on : 12 / 31 / 2025

Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state and local laws.