Compliance Auditor

Provider Network Solutions, LLC; Miami (FL); On-site; USD 70,000 - 110,000; Full time

Job summary

Provider Network Solutions, LLC is seeking a Compliance Auditor to review business practices and enforce healthcare regulations. Role includes auditing, reporting findings, and driving corrective actions in collaboration with the Compliance Officer.

Candidates should have 3–5 years in operational audits or regulatory compliance, with knowledge of Medicare/Medicaid rules. Strong communication, analytical, and organizational skills are essential.

Qualifications

• Bachelor’s degree preferred; 3–5 years in operational audits or regulatory compliance.
• Healthcare regulations knowledge including Medicare/Medicaid.
• Bilingual abilities preferred.
• Compliance certification is desirable.
• Experience with audits and monitoring processes.

Responsibilities

• Promote a strong code of ethics and integrity.
• Stay abreast of healthcare laws, regulations and standards, including Medicare, Medicaid and Commercial regulations.
• Assist in risk/issue identification and remediation within audits and delegation oversight audits.
• Resolve compliance issues identified through audits, coordinating with department leaders.
• Monitor quality of audited processes and mitigate risks with the Compliance Officer.
• Analyze, organize and document findings from audits, prepare reports and CAPs.
• Conduct internal audits and present results to the Compliance Officer.
• Handle external audits, manage data collection, dissemination and closure notices.
• Maintain organized audit records and CAPs log.
• Provide training and guidance on compliance matters.

Skills

Bilingual

Regulatory knowledge

Presentation skills

Communication skills

Analytical skills

Attention to detail

Time management

AI knowledge

Education

Bachelor's degree preferred

Tools

Microsoft Office

Job description

Description

Position Summary

The Compliance Auditor is responsible for the review of the company and delegated entities’ business practices, enforcing compliance with pertinent regulations, such as all federal and state relevant regulations and standards, applicable contractual requirements established by the organization’s clients and internal policies and procedures. Such audits and/or monitoring may occur annually or at other intervals and may include reviewing documentation and other records, as well as interviewing executives and employees. In instances where a potential and/or current non-compliance with a regulation or set of regulations is identified, the Compliance Auditor is responsible for recommending improvements to business processes to ensure that the operational department comes into compliance. Additionally, the Compliance Auditor is charged with evaluating the plan to implement any needed change, ensuring that steps within the plan are effective and addressing the root cause of the non-compliance issue.

Duties and Responsibilities

• Promote a strong code of ethics and integrity.
• Stay abreast of changes in healthcare laws, regulations and standards, including, but not limited to, Medicare, Medicaid and Commercial regulations and advise the company of requirements and changes, if any, required to be implemented by the Company.
• Assist in risk/issue identification and remediation within the external and internal audits and delegation oversight audits.
• Resolve compliance issues identified through internal and/or external audits or monitoring, while working closely with all operational department leaders and/or delegated entities’ point of contact (POC) to ensure prompt response to the compliance issues and that effective procedures are in place.
• Responsible for monitoring and maintaining the quality of the audited processes performed in each of the departments in accordance with the applicable lines of business and specialty network while collaborating with the Compliance Officer to improve processes and mitigate risks.
• Responsible for analyzing, organizing and documenting the findings arising from the audit and/or monitoring exercises, preparing reports containing findings, and requesting and implementing corrective action plans.
• Conducting internal audits, developing quality indicators to measure standards, developing internal audit tools as necessary and presenting the results of evaluations/audit reports to the Compliance Officer.
• Handle and oversee all external audits, ensuring that all steps are performed in a timely manner, such as but not limited to: Universes, questionnaires, samples and any request for information review, analysis, audit notices dissemination to impacted operational departments, recommendations for correction, internal discussions, preparation of data for final submission and receipt of formal closing notice.
• Maintain organized and up to date all audits’ records within the organization’s systems.
• Promptly address any Corrective Action Plans (CAPs) and/or non-compliance issues identified through an external audit with applicable operational department leader and delegate POC, and ensure accurate, effective, and complete evidence of completion is provided to the health plan partner auditor in a timely manner.
• Maintain the Audits and CAPs log and its evidence updated and well organized.
• Adhere to organizational policies and procedures to ensure compliance with the Compliance Program and contractual requirements, while serving as a departmental liaison to assist with the functions of the Compliance Program.
• Provides training and guidance to staff and delegates on compliance-related matters.
• Comply with performance standards as set forth by the Compliance department head.
• Perform other duties as required and assigned.

Requirements

Knowledge

• Bilingual, written and spoken (preferred).
• Bachelor’s degree preferred.
• Requires 3-5 years’ experience in operational audits, regulatory compliance or government regulations or
• any combination of education and experience, which would provide an equivalent background.
• Knowledge in Healthcare industry preferred.
• Medicare, Medicaid, and Commercial Regulations knowledge.
• Relevant experience in law, ethics, organizational business, finance, or statistical analysis.
• Experience in Audits and Monitoring processes.
• Compliance Certification is strongly desired.

Skills

• Proficient in Microsoft Office (word, excel and PowerPoint)
• Excellent presentation skills
• Must possess strong verbal and written communication skills (ability to communicate effectively with leadership and build relationships)
• Ability to communicate complex regulatory requirements in a clear and concise manner to a variety of audiences.
• Excellent research and analytical skills
• Thorough understanding of business requirements and excellent problem-solving skills
• Must be detail oriented and have excellent organizational and time management skills
• AI knowledge