Mgr, Audit Readiness

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 

This position manages the execution of the annual Federal Govt initiated regulatory audits and serves as the organizational liaison with CMS for Commercial/GP. This position collaborates with all levels of business partners across the Enterprise to resolve negative audit results which are subject to all levels of corrective action from CMS. The incumbent will lead a team of analysts that will review the findings, which can include civil monetary penalty, discontinuation of Medicare contracts, reject plans for expansion, suspended market activities and warning notices. This position also manages audit readiness across the Enterprise. This is done by hosting “mock’ audits with the business that align with published audit protocols.

• Functions as the Organizational liaison with federal auditors, and ensures organizational deliverables are aligned with CMS expectations. 

• Compiles business responses, universe data, hosts audit sessions, secures executive agreements and signs off.  

• Initiates corrective actions based on findings, provides guidance to business stakeholders regarding the audit protocols and expectations and will manage the compliance regulatory staff performance.

• Manages and updates the CMS audit playbook to ensure readiness appropriate key stakeholders and day 1 through end of audit  step by step expectations, as well as manages “mock program audit” reviews quarterly with the business owner

• Develops the Annual Audit Readiness Plan in collaboration with the Director, Commercial/GP Compliance, and VP, Regulatory Compliance, as well as prepares and disseminates Annual Audit Readiness results with the Director, Commercial/GP and VP, Regulatory Compliance.

• Disseminates the CMS Audits and Compliance Audit Readiness Plan to the affected business stakeholders and provides guidance related to same.

• Manages the CMS Audits and Annual Audit Readiness Plan in collaboration with the Director, Commercial/GP Compliance and VP, Regulatory Compliance. 

• Prepares reports on the Braven Compliance Oversight Committee.

• Partners with the Director, Commercial/GP Compliance and VP, Regulatory Compliance on Mock Audits for oversight activities. 

• Collaborate with Regulatory Audit and Internal Audit to ensure alignment with regulatory requirements.

Education/Experience:

• High School Diploma/GED required.

• Bachelor degree preferred or relevant experience in lieu of degree.

• Requires a minimum of five (5) years of relevant experience, preferably in Medicare Compliance, and Monitoring/ audit readiness.

• Experience managing teams or leading project work/initiatives preferred.

Knowledge:

• Health insurance industry knowledge; including Medicare, Medicaid, or Commercial health plan requirements.

• Prefers federal government audit knowledge.

• Prefers analytics experience.

• Prefer experience with CMS Program Audit.

Skills and Abilities:

• Organization and management of multiple priorities

• Analytical

• Strong written and verbal communication skills

• Attention to detail.

• Problem solving

• Leadership

• Soft skills

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

$108,000 - $147,420

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

• Comprehensive health benefits (Medical/Dental/Vision)

• Retirement Plans

• Generous PTO

• Incentive Plans

• Wellness Programs

• Paid Volunteer Time Off

• Tuition Reimbursement

Disclaimer:
This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.