Independent Certified Internal Auditor - Example Job Description
JOB DESCRIPTION
TITLE: Independent Certified Internal Auditor (CIA)
REPORTS TO POSITION: Reports to the Mental and Behavioral Health Practices Contract Audit Committee (Contract Audit Committee, or CAC).
PROGRAM: Mental and Behavioral Health Practices Contracting.
DATE LAST REVIEWED: February 29, 2024
OUR VISION: Ethical Conversations and Independent Audit Maintains Quality and Creates Quality Improvement.
OUR MISSION: In the spirit of compassion, better health, better care, better value.
OUR VALUES: Evidence-Based Care, Patient-Centered, Improved Quality and Health at an appropriate cost.
BUDGET/SALARY: The estimated total pay for an Internal Auditor is $160,000 to $180,000 per year in the Portland, Oregon area.
VENDOR CAPABILITY SUMMARY: The Independent CIA oversees, prioritizes, and recommends mitigation for clinical, ethical, legal, compliance, regulatory, financial, and other risks to Healthplan Operations and Provider Practices. The Independent CIA works with the CAC to implement policies and practices that prevent risks from becoming manifest. In addition, the Independent CIA provides advice, counsel, and support to the Contract Audit Committee on legal, audit, compliance, and risk matters created by contracts between Healthplans and Provider Practices. The Independent CIA also works to develop and model a culture that supports and encourages adherence with applicable laws and regulatory codes of conduct and ethical principles with transparency in assigned personal and business dealings and demonstration of integrity and respect in all interactions.
The Independent CIA will gather, aggregate, analyze and report on controls using existing or proposed values, objectives, and key performance indicators used by Healthplans. The Independent CIA also will have the capacity to identify values and objectives, and propose strategies that (1) value diversity, (2) consider a range of patient sub-populations, (3) which recognize the dynamics of difference, (4) acquire and incorporate cultural knowledge and human differences, and (5) adapt to diversity and the cultural contexts of provider practices who work population who are marginalized and underserved.
The Independent CIA advises the CAC of regulatory compliance and internal auditing while maintaining a collaborative relationship with evolving networks of mental and behavioral health services and operations in Oregon. In addition, this position is responsible for:
Recommending standards and procedures which ensure that contracts signed throughout the network are effective and efficient in identifying, preventing, detecting, and correcting unfair Healthplan contract practices,
Providing data informed reports to the CAC and the public regarding contract values, objectives, requirements, controls, and risks.
Communicating the underlying framework of contract expectations and requirements,
Educating decision makers regarding applicable laws and required regulations.
The Audit Officer has direct reporting responsibility and unfettered access to the Contract Audit Committee.
ESSENTIAL FUNCTIONS AND DUTIES (As directed by the CAC):
The Audit Officer may perform additional duties of similar complexity as required or assigned by the Contract Audit Committee.
AUDIT, COMPLIANCE AND PRIVACY CAPABILITIES (as directed by the CAC).
Annual Internal Audit Work Plan: Develops and executes the annual audit plan through communication with the CAC and external auditors as appropriate. Leads the execution of the audit work plan focused on assessing and enhancing controls and compliance with laws and regulations.
Audit Documentation: Prepares, reviews, and maintains completed audit work papers documenting the basis for the recommendations made relative to the assignment; ensures documentation and support for all work performed and conclusions made; ensures workpapers are assembled according to professional auditing standards.
Audit Services: The AO performs compliance and contract audit assignments, and other audit services as directed by the CAC.
Audit Supervision: Supervises consultants and audit interns contracted to perform audit projects and/or activities.
Auditing Best Practices: Maintains awareness of changes in auditing principles and practices and related areas to maintain professional competence. Participates in professional groups devoted to audit and advances in healthcare auditing practices. Actively seeks knowledge of new, automated, or more efficient audit techniques to increase efficiency and effectiveness.
Business Risk: Leads the review and education of business risks through contract and compliance audits or other activities of the provider network. Executes audit planning by performing research to assist in development of appropriate audit scope, audit programs, testing procedures relevant to risk and objectives, timelines, workflows, and budgets.
Healthplan Audit Reviews: The Independent CIA will review Healthplan audit plans for proposed, ongoing and previous audits of providers so as to inform and educate providers where appropriate. The Independent CIA will understand Healthplan provider audit procedures sufficiently such that the Independent CIA could conduct an independent provider audit and reach the same conclusions.
Conflicts of Interest Process: Oversees the CAC’s conflicts of interest process and serves as the primary reviewer of potential conflict of interest disclosures to the CAC. Works under the supervision of legal counsel for privileged matters as appropriate.
Contract Review Program: Develops, administers, updates, and oversees a comprehensive, network-wide Contract Review Program and strategic plan consistent with the recommendations of the provider experts, provider practice associations, industry thought-leaders, the U.S. Department of Health and Human Services and the Oregon Health Authority.
Corrective Action: Appraises the adequacy of action taken by Providers Practices to correct reported deficient conditions and takes follow-up measures as required until all significant issues have been satisfactorily resolved.
Policy Violations/Corrective Action Plans: Recommends a system for uniform handling of potential Healthplans violations of applicable contract provisions, policy, rules, laws, and regulations including recommending corrective action plans. Ensures proper reporting of violations or potential violations to duly authorized legislative or enforcement agencies as appropriate and/or required. Works under the supervision of legal counsel for privileged audits and reviews.
Promotion of Ethical Culture: Recommends effective network-wide education and training that promotes a culture that fosters ethical behavior and ensures CAC activities are provided in accordance with applicable policies, laws, regulations, and the Providers’ Codes of Conduct and requirements for licensure.
Contract Risk Management: Collaborates with the CAC to develop and maintain a Contract Risk Management Program.
GENERAL CAPABILITIES
Confidentiality/Professionalism/Compliance with Regulations: Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting compliance efforts by acting in an ethical and appropriate manner.
Continuous Improvement: Supports principles of continuous improvement with energy and enthusiasm, functioning as a champion of change that protects public health and provider practices.
Reporting: Regularly reports to the CAC, regarding key areas of risk and needed actions related to audit activities.
Key Areas for Audit of Healthplan Created Risks which Impact Objectives
Healthcare privacy and confidentiality policy
Healthcare privacy and security policy
Minimum necessary information regulations
Charting methods and requirements
Benefits and eligibility
Healthplan audits of provider practices
Use of Common Procedure Terminology (CPT)
Diagnosis
Contract management cycles
Contract errors and omissions
Contracts is not fair and/or made in good faith
Asymmetric information detrimental of patient care and public health
Disproportionate risk to the detriment of patient care, public health, and provider practices
Risk share requirements and feasibility
Risk adjustments requirement and feasibility
Reimbursement rate changes
Incentives
Baselines and benchmarks
Algorithms used to measure performance
Screening, progress and outcome measures
Shared values and objectives
Transparent controls
Key performance indicators
Risks-impacting objectives (RIO)
Risk Control Matrix (CRM)
Residual Risk Analysis
EDUCATION
Required: Master of Business Administration (MBA) and Certified Internal Auditor (CIA), Certified Public Accountant, and Certified Internal Auditor (CIA).
Preferred: N/A
CERTIFICATION/REGISTRATION
Required: Independent Certified Internal Auditor (CIA).
EXPERIENCE
Required: Minimum ten (10) years’ experience in internal audit, accounting, and compliance in health care (a highly regulated industry. Minimum five (5) years’ experience managing, guiding, mentoring, and motivating a team in a complex organization with demonstrated skills in developing strong collaborative relationships with Boards or Audit Committees. Must have a demonstrated moderate level of practical experience in a multi-function, multi-entity environment, with competencies in system-wide program planning and project management. Proficient in collecting and analyzing business processes, workflows, and control relationships.
Preferred: Familiarity with operational, quality assurance and improvement.