Senior Health Insurance Auditor

Job Description

Job Description

Purpose of the Job

The Senior Health Insurance Auditor position at HNE is a key member of the team that ensures there is an effective process of monitoring internal controls and risk mitigation.

This position will review financial and operational areas to verify that HNE is operating within the policies, procedures, and regulations set forth by HNE and by state and federal laws, including Medicare and Medicaid.

This position will objectively assess business processes and risks, evaluate internal controls, make recommendations on improvement opportunities and validate corrective actions are implemented.

This position serves as a liaison to external auditors, regulators, consultants, and internal stakeholders to coordinate deliverables and assist management as needed.

Enterprise Risk Management responsibilities include gathering information from internal associates to support key risk indicators for reporting purposes, coordinating risk management related meetings, and assisting in all Enterprise Risk Management related assignments as directed.

This position reports directly to the Sr. Director, Revenue Assurance and Risk Management and will exercise a high degree of independent judgment in determining relevant information needed to perform an adequate review.

This individual will have access to all relevant personnel, documentation and records in the areas under review

Accountabilities

• Champions a customer focused culture to deepen client relationships and leverage broader Health New England’s relationships, systems and knowledge.
• Understand how Health New England’s culture and the CX Promise should be considered in day-to-day activities and decisions.
• Actively pursues effective and efficient operations of their respective areas in accordance with Health New England’s Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
• Champions a high performance environment and contributes to an inclusive work environment.
• Is responsible for maintaining and adhering to internal controls, ensuring compliance with applicable laws and regulations, and following Health New England’s entity level policies and procedures.
• Is responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England’s Code of Conduct.

Essential Job Functions

• Document, monitor, and execute testing of controls to validate Internal Controls over Financial Reporting and Operations are designed appropriately and operating effectively.
• Development and execution of annual MAR schedule, including the validation and testing of internal controls in support of Model Audit Rule compliance.
• Scope, plan, and execute risk-based audits for financial and operational business areas. Responsible for conducting process walk-throughs, completing process flow documentation, risk and control identification, control testing, and drafting audit reports to be presented to senior management and the Audit Committee of the Board of Directors.
• Identify, communicate, and document control gaps and deficiencies and work with responsible issue owners to ensure effective remediation is completed.
• Make recommendations for improving operational controls, including efficiency and effectiveness to strengthen the company’s control environment.
• Monitor, track and facilitate responses to external reviews and audits such as Division of Insurance financial exams, 3rd party audits, etc. as assigned.
• Substantially contribute to Board-level reporting on Audit and Assurance activities.
• Collaborate with peers to ensure policies and procedures are reviewed regularly and updated as necessary to ensure accurate reflection of current processes & requirements.

Primary Manager :

include secondary Manager if applicable)

Sr. Director, Revenue Assurance and Risk Management

Direct Reports : N / A

N / A

Shared Reports (solid / dotted if applicable) : N / AExternal / Internal Contacts

Internal

Revenue Assurance and Risk Management

External

HNE vendors

Education / Experience / Other Information (include only those that are specific to the role)

Bachelor’s degree in Finance, Accounting, Business or related field with a minimum of 5-7 years’ experience in an internal or external insurance related audit role.

Additionally, a background in health insurance preferred.

Demonstrated knowledge of healthcare financial and operational internal control methodologies and terminologies (e.g. COSO, NIST, and COBIT);

process and control industry standards; risk management practices and techniques; and internal audit process, technology and tools for planning, design, performance, testing, and reporting.

• Strong process / work flow development and solid experience in testing, evaluating, and documenting controls.
• Strong knowledge of, and exposure to, any of the following : SOX / MAR, HIPAA, and / or Government Payer Operations (CMS, ACA, and Medicaid).
• Ability to think through complex problems, determine proper analytical processes and procedures, independently derive conclusions, and present results to management.
• Ability to understand and comprehend government health insurance laws and regulations.
• Ability to work well independently and collaboratively and earn the trust of management and key stakeholders.
• Proficiency in Microsoft Office suite and Visio.
• Excellent written and oral communications skills.
• Assists with improving HNE’s existing Enterprise Risk Management program
• Coordinates meetings, follow-ups, and gathering artifacts needed to support Risk Management and Internal Audit initiatives
• Assists with validation and assessment of identified risks or weaknesses

Preferred :

• Certified Public Accountant (CPA) or Certified Internal Auditor (CIA).
• Experience with health care data reporting and analysis.
• MBA or Master’s Degree is a plus.

Working Conditions

Standard office environment, with extended period of time sitting, looking at monitors, typing on laptops and communicating via softphones / headsets for virtual meetings.

No traveling required.