Network Compliance Auditor, FSR

Job description

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. The Job Performs various oversight and audit activities to ensure compliance with CMS and local requirements. This may include: testing, monitoring, documenting and reporting the overall level of compliance with CMS and local requirements for designated audit area (Authorizations, Credentialing, Compliance Programs, Claims, Utilization Management, Special Needs Plan, etc.) achieved by SCAN internal operations and First Tier, Downstream, and Related Entities (FDR); and/or monitoring and auditing CMS required data submissions to ensure compliance with CMS regulatory requirements. You Will Performs on-site and desktop auditing of SCAN internal processes and FDRs including SCAN's delegated groups, IPA’s, hospitals and ancillary providers in accordance with CMS and DHCS and contractual requirements to ensure compliance Recognizes and communicates areas for improvement to network providers Prepares detailed written results of oversight audits by communicating findings, areas of concern and recommendations for improvement, including corrective action requests in accordance with P&P’s Makes recommendations for development of policies and procedures, as well as work flow charts Conducts closing meetings with audited providers to give them a preliminary overview of completed compliance audits Assists providers in achieving and maintaining compliance with SCAN, Federal, State and NCQA requirements and guidelines including the development and implementation of corrective action plans (CAP), monitoring CAP activities and providing education and tools Responds to audited providers as disagreements with audit findings arise Analyzes submitted reports from providers, including the request for corrections from providers as needed Communicates regulation interpretations and explains their application, provides supplemental information if needed Conducts detailed review, analysis, and interpretation of legislative, statutory, regulatory, and contract language Conducts all aspects of annual oversight projects, including creation and distribution of mass mailing and individual correspondence; coordination of projects with internal SCAN staff and departments; monitoring and reporting delegated compliance; tracking, trending and reporting upon project status; coordinating with Compliance regarding report submissions and HPMS/regulatory updates Uses critical thinking skills and identifies impactful areas for provider data requirements to develop an effective implementation and communication plans Functions as the service delivery compliance subject matter expert by representing the Delegation Oversight Unit (DOU) in interdepartmental meetings and partnering with Compliance to develop and implement SCAN policy regarding NCQA, DHCS, CMS and/or other regulatory revisions Utilizes department desktop procedures, workflows, job aids and training material Escalates longstanding issues of non-compliance in accordance with P&P’s Identifies barriers and brings to the attention of the supervisor/manager Educates providers on such topics as compliant delegated claims processing and the denial of claims with member liability in accordance with CMS, local state and SCAN contractual requirements Maintains the member‘s right to privacy and protect SCAN operations by keeping information confidential Reviews letters from internal and delegated administrators, Compliance Program processes, or data submissions for accuracy and compliance with CMS and contractual requirements, and recommends delegation status based on results Adheres to all quality, compliance and regulatory standards to achieve SCAN outcomes This role requires driving in assigned territory. We seek Rebels who are curious about AI and its power to transform how we operate and serve our members. Actively support the achievement of SCAN’s Vision and Goals. Other duties as assigned. Your Qualifications Associate's Degree or equivalent experience 0-3 years of related FSR Auditing experience. Performs work under direct supervision. Handles basic issues and problems, and refers more complex issues to higher-level staff. Possesses beginning to working knowledge of subject matter. Technical expertise - Basic technical skills for functional area Problem Solving - Basic problem-solving skills Communication - Good communication and interpersonal skills This role requires driving in assigned territory What's in it for you? Base Pay Range: $38.61 to $55.86 per hour Work Mode: Remote/Field (This role requires driving in assigned territory) An annual employee bonus program Robust Wellness Program Generous paid-time-off (PTO) along with 11 paid holidays per year, 1 floating holiday, birthday off, and 2 volunteer days Excellent 401(k) Retirement Saving Plan with employer match Robust employee recognition program Tuition reimbursement An opportunity to become part of a team that makes a difference to our members and our community every day! We're always looking for talented people to join our team! Qualified applicants are encouraged to apply now! At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. #LI-JA1 #LI-Hybrid Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)