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Sr Compliance Auditor, Clinical
at agilon health
Anaheim, CA

Sr Compliance Auditor, Clinical
at agilon health
Anaheim, CA

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Job Description

Position Summary:

The Sr. Compliance Auditor is responsible for leading audits of external vendors and internal departments to ensure regulatory and contractual compliance requirements. The auditor also participates in the planning and development of tools, strategies, and educational resources that promote best practices in compliance.


Essential Job Functions:


  • Lead compliance audits on Utilization Management (UM) and Case Management (CM) activities relative to Medicaid and Medicare, and ensure processes are compliant with NCQA, CMS, DHCS, and DMHC regulatory standards.
  • Identify and provide guidance on remediation activities, train staff on compliance requirements and controls, if needed.
  • Develops & implements unit workflows, audit tools, policies & procedures related to auditing and chart reviews.
  • Assists in reviewing material for submission to audits (external, mock, or regulatory), and due diligence activities.
  • Requires accurate tracking and recordkeeping; coordinating audits or interviews; and creating/delivering presentations.
  • Facilitates the review and oversight process, including the corrective action updates.
  • Interacts closely with other compliance department personnel on all compliance related activities.
  • Conducts oversight audits of health plan procedures and processes to verify compliance with contractual and regulatory requirements and to identify fraud.
  • Review and evaluate treatment authorization standards and processes that focus on accuracy, completeness, timeliness, completion of documentation.





Other Job Functions:


  • Understand, adhere to, and implement the Company’s policies and procedures.
  • Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients.  Proactively ensuring that these needs are met or exceeded.
  • Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
  • Engage in excellent communication which includes listening attentively and speaking professionally.
  • Set and complete challenging goals.
  • Demonstrate attention to detail and accuracy in work product.


Required Qualifications:


Minimum Experience

  • Three years’ experience in managed care setting
  • Two-three years’ experience in compliance auditing
  • Three years’ clinical nursing experience
  • Requires specialized knowledge in the areas of contracts, Medicare Advantage, Medi-Cal HMO and commercial regulations and reimbursement rules and coordination of benefits
  • Knowledge of NCQA standards



  • Bachelor’s degree in Nursing, Business, Health Care Administration or related field or equivalent education and experience
  • CA LVN or RN License required


Skills and Abilities:

Language Skills: Strong communication skills both written and verbal to work with multiple internal and external clients in a fast-paced environment Mathematical Skills: Ability to work with mathematical concepts such as probability and statistical inference.  Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations. Reasoning Ability: Ability to apply principles of logical or scientific thinking to a wide range of intellectual and practical problems.  Computer Skills: Ability to create and maintain documents using Microsoft Office (Word, Excel, Outlook, PowerPoint)


Company Description

The passion to change the way healthcare is delivered permeates everyone and everything at agilon health. Working together we can use our expertise to make a difference in the lives of patients and physicians alike. We can bring the joy back to practicing medicine for physicians and improve the care experience for patients across the country.

We believe that every member of our team plays a critical role in transforming care for our patients. Our customer service teams are the front line for physicians and patients navigating the system and, without our claims processing departments, our health plan partners and provider networks couldn’t do their jobs. No matter what your role is at agilon health, you can and will make a difference in the lives of the seniors and Medicaid populations we serve. Our culture and passion has already been embraced by nearly 500 employees in three states. And we are excited to welcome new members to the team as more physicians and patients experience the difference agilon health can make.

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