Network Compliance Auditor, FSR

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 and provides oversight to the Managed Care Plan's (MCP) Department of Health Care Services (DHCS) auditing team responsible for conducting and overseeing both initial and subsequent reviews of Primary Care Provider (PCP) sites. These reviews include a Facility Site Review (FSR) and a Medical Record Review (MRR), utilizing the tools and standards set by DHCS. The site review process is an integral part of the MCPs quality improvement programs, focusing on each PCP site's capacity to provide safe and effective clinical services. Support monthly audit assignments by completing all required audit work within the established timelines, and ensure the documentation is thorough and aligned with regulatory and compliance requirements. You Will Conducts detailed review, analysis, and interpretation of DHCS All Plan Letters (APL) and works with designated DHCS-CMT and manager to deploy. Using critical thinking skills, identify impactful areas for regulatory compliance to develop an effective implementation communication plan. Facilitates the auditing of SCAN contracted and collaborative PCP offices that see Medi-Medi members, in accordance with CMS and DHCS and contractual requirements to ensure compliance. Provides training on all aspects of auditing and post audit documentation, providing feedback and identifies opportunities for improvement. 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, 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 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 and have the ability flex to other areas as assigned.  Must have a valid driver’s license, automobile insurance and reliable transportation 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 Registered Nurse License required (current and active California license in good standing).   2+ years Clinical experience including but not limited to ER/Acute Care nursing required. IPA, Medical Group experience preferred. Associate's Degree in Nursing, Bachelor's Degree preferred. DHCS-CSR (certified site reviewer) preferred. Prior auditing experience preferred . Must be able to work independently as well as in a team environment. 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