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The Senior Health Plan Auditor is responsible for planning, executing, reporting, and monitoring corrective action plans related to financial solvency and claims processing compliance for specialty health plans and vendors. This role ensures compliance with regulatory requirements and contractual agreements across all lines of business. The position also serves as a subject matter expert and mentor, supporting junior staff and contributing to process improvements and regulatory readiness.
Job Responsibility:
Perform financial audits and analyses for specialty health plans and vendors
Conduct claims processing audits to ensure regulatory and contractual compliance
Ensure timely and accurate audit deliverables related to financial solvency
Support quarterly and annual DMHC claims data submissions
Serve as liaison for CMS claim audits related to L.A. Care delegates
Monitor, track, and report corrective action plans and non-compliance notices
Assist in developing standardized audit workpapers and reporting templates
Maintain and annually update departmental Policies & Procedures (P&Ps)
Support legal, delegation oversight, and regulatory requests
Collaborate with internal departments, leadership, vendors, and plan partners
Identify opportunities for process improvement and technical solutions
Provide training, mentorship, and guidance to junior staff and interns
Participate in special projects and regulatory impact assessments
Requirements:
Bachelor’s Degree in Accounting or a related field (required)
Minimum 3 years of experience conducting financial audits
Minimum 5 years of experience in the managed healthcare industry
At least 2 years of accounting experience
Strong analytical and critical-thinking skills
Excellent verbal and written communication abilities
Ability to work independently with minimal supervision
Strong organizational and prioritization skills
Professional communication with internal and external stakeholders
Proficiency in Microsoft Excel, PowerPoint, and SharePoint
Action-oriented, self-motivated, and detail-focused
Must hold one of the following certifications: Certified Public Accountant (CPA), Certified Management Accountant (CMA), Certified Internal Auditor (CIA), Certified Fraud Examiner (CFE)