Position Summary: The Medicare Advantage Auditor will assist in identifying, addressing, and monitoring risks pertaining to Martin’s Point’s Medicare Advantage product line. In addition, the auditor is responsible for the execution of the Medicare Advantage annual audit plan and monitoring/oversight of applicable corrective action plans to ensure plan activities conform to applicable federal and state laws as well as programmatic guidelines established by The Centers for Medicare and Medicaid Services (CMS). The auditor also will assist with audit activities and compliance for Martin’s Point’s Uniformed Services Family Health Plan (USFHP), a TRICARE Prime option open to military families and certain retirees.
Leverage CMS audit protocols and universe requirements, execute internal compliance audits to systematically review specific functional areas of the organization for compliance with applicable laws, regulations, policies, procedures, and the Company's Compliance Program requirements, specifically in the areas of Medicare Advantage (Part C) and Prescription Drug (Part D) regulations.
Monitor and conduct testing of USFHP programmatic compliance with the TRICARE Operations Manual (TOM) and applicable programmatic guidance.
Conduct internal audits and/or process reviews with cross-functional teams including compliance with stated policies, procedures and/or workflows related to the scope of audit.
Prepare audit work papers and reports to effectively conduct, document, and communicate all compliance audit activities. Compose audit reports which accurately outline any findings as a result of the audit work.
Review corrective action plans received in response to audit findings; collaborate with the submitting department on any necessary changes.
Track corrective actions and follow-up with responsible parties to ascertain completion status. Report any resource constraints or support needed to applicable leadership to collaborate on actions needed for the responsible parties to successfully complete requirements to achieve compliance.
Review corrective action plan evidence to assess whether all corrective actions were taken appropriately and that the evidence demonstrates programmatic compliance.
Compile data to report on audits performed, findings, level of risk, corrective action plans, and outcomes. Assist in evaluating the effectiveness of the audit program.
Assist applicable areas in the execution of the first tier, downstream, and related entities (FDRs) Oversight Program including but not limited to audit and monitoring of the Company's FDRs to confirm compliance with applicable laws, regulations, policies and procedures as well as Martin’s Point Health Care’s Code of Ethics.
Maintain education, awareness, and knowledge of current regulations and best practices in the health care industry and in the audit and monitoring function including CMS audit protocols, common findings and best practices. Bring regulatory changes and matters of significance or urgency to the Medicare Compliance Officer’s attention.
Communicate the status of regulatory and/or operational projects to supervisor, internal individuals and/or teams, and external clients, in a timely manner.
Subject matter knowledge – Possesses a working knowledge of Medicare Part C and Part D, the Medicare Managed Care Manual and Prescription Drug Benefit Manual as well as other State and Federal laws and regulations (e.g., HIPAA, False Claims Act, anti-Kickback Statute, Civil Monetary Penalty laws, etc.)
Performs other duties as assigned
Demonstrates an understanding of and alignment with Martin’s Point Values.
Demonstrable understanding of and proficiency with CMS audit protocols and applicable Medicare Part C and Part D regulations.
Ability to independently and effectively read and research regulatory material, analyze and apply regulatory requirements to operations.
Ability to establish and maintain exceptional relationships of trust with Martin’s Point business partners and government oversight personnel.
Strategic thinking and planning, process development and performance measurement skills.
Approach work assignments in an organized, process-focused manner, which fosters the achievement of effective results.
Ability to be flexible with changing priorities and work in a fast-paced environment
Excellent writing skills required. Must be able to write in a professional, clear, concise manner and communicate technical program requirements effectively in writing
Self-motivated with ability to manage, prioritize and complete multiple projects in a timely fashion with limited supervision
Bachelor’s degree required or equivalent combination of education and work experience in relevant field accepted.
3+ years federal program compliance and/or auditing experience.
Substantial experience with Medicare Part C and D health plan operations and best practices highly preferred.
Prior experience with CMS program audits preferred.
Microsoft Office Applications (e.g, Access, Excel, Work, PowerPoint, Visio) experience and proficiency.
Certification in Healthcare Compliance (CHC) or other Compliance certification preferred.
Martin’s Point is a health care organization leading the way to provide better care at lower costs in the communities we serve. As a not-for-profit organization, our primary mission is to create a healthier community through authentic relationships built on trust. Our administrative offices are located in Portland, Maine, though our health plans and Health Care Centers have a much broader reach in... Maine and beyond.
Join an innovative Healthcare company and consider joining Martin's Point's mission to create a community of healthy people through authentic relationships and trust. "People caring for people". Our vision is that we are trusted for care, chosen for service and uniting the community in affordable healthcare. We were chosen as one of the TOP 5 healthcare companies in the country. If you are interested in building on your talents in a caring and fun environment, please apply.
Seascapes and cityscapes blend harmoniously in Portland, perched on a peninsula, jutting out into island-studded Casco Bay. Portland is a progressive, lively city incorporating the character of yesteryear into a modern urban environment. With a metro population of 230,000, the Greater Portland area is home to almost one quarter of Maine's total population. Portland is an easygoing city with friendly, hardworking people and a region that abounds in year-round outdoor recreation from the ocean to the mountains. Ranked nationally as one of the ten safest, culturally most fascinating US cities and one of the top cities for doing business, housing is affordable, and the schools and healthcare are outstanding.