Performance Oversight Specialist ll (Internal Audit / Control)

Job Purpose:

This position is responsible for providing direct support to the Manager Medicare Performance Oversight with ensuring effective implementation and ongoing oversight/ monitoring of regulatory requirements for Medicare plans. The role will provide oversight and review assistance for all aspects of the Medicare operations initiatives, and will serve as primary resource in monitoring the performance of the internal control environment for Government Programs Division (GPD). This role will be responsible for conducting periodic department reviews of GPD's Group and Individual Medicare Advantage, Medicare Part D and Medicare Supplement operations. The Medicare Performance Oversight Specialist II will document risks and issues through the interpretation of CMS contract requirements to ensure compliance with applicable laws and regulations; escalating findings and making preliminary recommendations and corrective action steps to the Manager Medicare Performance Oversight.

Job Responsibilities:

• Provide direct support to the administration of the system of controls across the enterprise for Medicare programs (including policies, reporting required, status updates / frequency, etc.). Specific areas of oversight responsibility may include, but is not limited to, the following:

  • Producer Oversight
  • Delegation Oversight
  • Appeals & Grievances
  • Pharmacy
  • Enrollment / Claims
  • Marketing Submissions

• Responsible for measuring performance and ensuring that any risks are escalated to support the implementation and execution of corrective action plans developed in response to CMS audits and communications, Medicare performance oversight, and internal audits.

• Identify and administer progress measurement of corrective action plans to address weaknesses identified through the performance oversight function.

• Responsible for assisting with the development and the housing/maintenance of policies and procedures and supporting documentation to comply with CMS and various program requirements.

• Responsible for administering/monitoring programs and developing reports that measure performance against internal and external requirements; report periodic results to the Manager Medicare Performance Oversight

• Perform tests to validate data submitted; conduct ongoing analysis of performance reports, identifying data weaknesses and performance improvement opportunities and presenting recommendations to management

• Primary support resource for HCSC Medicare program related audits from either CMS or Internal Audit. Develop training and communication materials as required to support roll-out of new monitoring programs, policies, etc.

Required Job Qualifications:

• Bachelor's degree and 4 years' work experience in a Medicare or managed care environment or 8 years' work relevant work experience in a Medicare or managed care environment with relevant experience in one or more of the following areas: audit, health plan operations, compliance, legal and/or other related positions.
• Prior experience with process improvement activities, policy/procedure development, and operational efficiency
• Knowledge of health care regulatory and legislative process; ability to read and interpret legislation
• Strong verbal, written, research and analytical skills required
• Demonstrated ability to manage multiple complex priorities, often with limited timeframes
• Interpersonal skills; ability to interact effectively and professionally with all levels in the organization
• Detail orientation and organizational skills; ability to meet deadlines on time
• Experience with Microsoft Office products including Work, Excel and Access

Preferred Job Qualifications:

• Working knowledge of CMS requirements related to MAPD
• 4 years' experience with Group or Individual Medicare Advantage, Medicare Part D and / or Medicare Supplement
• Audit experience


HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants. We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.
Requirements: Expertise Other, Audit, Government Programs Job Type Full-Time Regular Location OK - Tulsa, MT - Helena, TX - Richardson, IL - Chicago, NM - Albuquerque

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