CCSB Administration Auditor

Pinnacle Health Solutions; Irvine (CA); On-site; USD 60,000 - 75,000; Full time

Job summary

Pinnacle Health Solutions is seeking an Administration Auditor I to perform comprehensive audits of the Administration team, ensuring adherence to standards and goals. The role involves coordinating audits, identifying training needs, and providing support to the Eligibility team based on audit findings.

Responsibilities include auditing various administrative processes, communicating findings to management, and distributing audit reports while supporting process improvements and policy updates

Qualifications

• BA/BS degree in an auditing role preferred.
• 1–3 years of work experience as an auditor in the health benefits industry preferred.
• Proven ability to communicate clearly in writing and verbally.
• Knowledge of HIPAA regulations and privacy practices.
• Strong proficiency with Microsoft Office and data reporting tools.

Responsibilities

• Audit additions, terminations, changes, new business, group setup, and call center transactions for all groups to ensure plan rule compliance.
• Identify training needs, support training development, and coordinate ongoing or ad-hoc training.
• Provide technical support and expertise to the Eligibility team or other departments as determined through audit findings.
• Communicate audit findings and recommendations to management, highlighting trends and metrics.
• Run, analyze, and distribute audit reports on established intervals; monitor progress and performance.

Skills

Auditing

Time management

HIPAA knowledge

Microsoft Office

Communication

Team collaboration

Education

BA/BS degree

Tools

Microsoft Office

Job description

JOB DESCRIPTION SUMMARYThis position reports to the Supervisor I, Enrollment and Eligibility. The CCSB Administration Auditor I develops and performs Audits of Pinnacle staff including in-depth audits of the Administration team to ensure adherence to standards and goals. The incumbent plans, coordinates, and conducts audits.DUTIES AND RESPONSIBILITIESTeam DevelopmentIdentify training needs, support training development, and coordinate ongoing or ad-hoc training.Provide technical support and expertise to the Eligibility team or other departments as determined through audit findings.Participate in the teams' developmental plans by providing additional auditing and basic coaching as needed through 1:1 conversation.Build strong relationships, identify individual strengths and areas for growth, and align personal goals with team objectives.Identify and escalate issues related to instructional material that are inaccurate or unclear. Revise and communicate corrections of this material to the team.Monitor and evaluate the progress of new/existing team members, providing constructive feedback and recognizing achievements.Confer with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.Assist management in identifying employee trends that suggest proficiency in certain areas that can lead to new responsibilities.Department OperationsConduct audits of adds, terms, changes, new business, group setup, and call center transactions of all groups to ensure compliance with plan rules and guidelines.Ensure all audit functions of the department, including new business, enrollment, carrier discrepancies, audits, and any finance-related issues are completed timely according to management schedule.Maintain a minimum audit accuracy rate and meet productivity requirements for auditing.Communicate effectively with members, and senior management as required discussing and resolving audit findings and recommendations, with a focus on presenting trends and metrics to upper management to support departmental needs.Maintain enrollment audits of adds, terms, changes, new business, group setup, and call center transactions of all groups to ensure compliance with plan rules and guidelines.Provide Audit data and metrics to measure the internal teams' performance quality accurately, adherence to procedures, and turnaround time.Assist the manager, supervisors, and trainer with training and development by reporting quality error trends.Run, analyze, and distribute audit reports for established intervals.Interface effectively with members, and senior management as required, discussing and resolving audit findings and recommendations.Process Improvement & Cost ContainmentSupport and assist the manager and supervisors in the development of procedural strategies and operations processing including department policies and guidelines.Ensure policy and procedures are accessible and current on CCSB SharePoint site.Assist with documenting processes that will reduce data entry errors.Review trends and participate in the rebuttal process for continuous development.Develop and enhance the audit process.Facilitate CCSB Appeals Process.OtherMaintain integrity and transparency in all tasks, ensuring alignment with team and organizational goals.Hold oneself accountable by taking ownership of actions, decisions, and their outcomes.Reflect on personal performance regularly, identifying areas for improvement and celebrating successes.Encourage open and honest communication, promoting a culture of mutual respect and continuous improvement.Commit to continuous learning and growth, seeking feedback and implementing constructive changes.Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.Maintain a HIPAA compliant workstation and utilize appropriate security techniques to ensure HIPAA required protection of all confidential/protected client and enrollee data.Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).All other duties as assigned.PHYSICAL DEMANDS/WORKENVIRONMENTThe physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.QUALIFICATIONSBA/BS degree and/or (1) one to (3) three years of work experience as an auditor in the health benefits industry preferred.Proven time management skills –including task management, establishing priorities, and working collaboratively to meet deadlines.Excellent knowledge of Health Benefits Exchange coverage, eligibility requirements, the application and enrollment processes, and health benefits systems.Ability to communicate verbally and prepare clear, concise written narratives, memoranda, and audit reports.Knowledge of Health Insurance Portability and Accountability Act (HIPAA).Intermediate computer experience with Microsoft Office Suite and the ability to develop a strong proficiency working with a proprietary Health Care system.Able to perform in-depth research and analysis on eligibility discrepancies and provide detailed documentation of the issue and recommendations for resulting actions.Ability to work cooperatively with colleagues, team members, employer groups, and members.Ability to maintain strict confidence of employer group confidential payroll information.Ability to work overtime based on department needs and compliance.Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.Home router with wired Ethernet (wireless connections and hotspots are not permitted).A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)A functioning smoke detector, fire extinguisher, and first aid kit on site.