Compliance Auditor II

Health Plan of San Mateo; Golden Horseshoe; Hybrid; CAD 80,000 - 100,000; Full time

Job summary

A leading healthcare organization is seeking an experienced auditor to conduct internal and external audits. The role involves preparing audit reports, ensuring regulatory compliance, and engaging with stakeholders. Candidates should have a Bachelor's degree and significant experience in managed care auditing.

Qualifications

• 5+ years of professional experience in a managed care environment.
• 3 years’ prior healthcare auditing experience.

Responsibilities

• Lead and coordinate internal and delegation oversight audits.
• Prepare post-audit reports and communicate findings.
• Develop and monitor corrective action plans.

Skills

Analytical skills

Communication

Teamwork

Education

Bachelor’s degree in health, business or public administration

Tools

Microsoft Office Suite

Job description

801 Gateway Blvd, South San Francisco, CA 94080, USA ● Virtual Req #149

General Description

Under general direction of the Government and Regulatory Affairs manager conduct internal and external audits that are routine and complex. Act as a subject matter expert resource to HPSM staff by providing a comprehensive explanation and interpretation of regulations and applicability to audits and audit findings.

Qualifications

The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:

Education and Experience

• Bachelor’s degree in the field of health, business or public administration.
• Five (5) or more years of professional experience in a managed care environment.
• Three (3) years’ prior healthcare auditing experience.

Knowledge

• Managed Care policy and operations, and the regulatory requirements pertaining to Medi-Cal, Medicare, and the Knox Keene Act.
• Delegation Oversight auditing, principles and requirements.
• Internal auditing, quality assurance, and/or quality improvement processes.
• Public health programs.
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.

Abilities

• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Use sound professional judgement to identify and escalate high risk audit findings to management and provide detailed information with examples.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Demonstrate strong analytical and research skills.
• Communicate effectively, orally and in writing, particularly in preparing reports.
• Interact with a variety of people in difficult situations.
• Work independently
• Prioritize and work on multiple assignments concurrently to ensure deadlines are met.
• Act as a subject matter expert on applicable knowledge areas.

Licensure /Certifications

• Not Applicable.

Driving

• Not Applicable.

DUTIES & RESPONSIBILITIES

Essential Functions

Audit Planning & Execution

• Independently create, maintain, and update audit tools in accordance with regulatory standards (DHCS, DMHC, CMS, HICE, NCQA, HPSM policies, etc.).
• Lead and coordinate internal and delegation oversight audits (annual, focused, and ad hoc).
• Conduct audits of operational functions with minimal supervision to monitor compliance with contracts, regulations, and program guidelines.
• Prepare business owners for audits by compiling materials, issuing guidance, and managing audit timelines and deliverables.
• Maintain accurate records of audit activities and ensure all related deadlines are met.

Regulatory Compliance & Corrective Action Oversight

• Prepare post-audit reports and clearly communicate findings to internal and external stakeholders.
• Develop and monitor corrective action plans (CAPs), escalating unresolved issues and recommending actions to mitigate risk.
• Review audit findings and advise management on potential organizational risks, penalties, or sanctions.
• Ensure compliance with internal policies and regulations across departments by recommending process improvements and supporting audit readiness.

Stakeholder Engagement & Knowledge

• Write and deliver formal audit correspondence, including pre- and post-audit communications, CAPs, and non-compliance notices.
• Present audit results and CAP summaries to Compliance and Delegation Oversight Committees.
• Serve as a subject matter expert on audit processes and regulatory requirements, offering guidance to internal staff and delegate partners.
• Provide informed suggestions to improve compliance and consult on the imposition of contract sanctions when appropriate.

Secondary Functions

• Adhere to work performance norms and attendance expectations.
• 801 Gateway Blvd, South San Francisco, CA 94080, USA