Senior Compliance Examiner/Auditor – MLR exams

Job Description Senior Compliance Examiner Position Overview The Senior Compliance Examiner/Auditor will assist in completing comprehensive Medical Loss Ratio (MLR) examinations in accordance with the procedures developed by the Center for Consumer Information and Insurance Oversight (CCIIO), a division of the Department of Health and Human Services (HHS) responsible for implementation of the Affordable Care Act (ACA). MLR Examinations may also be performed on behalf of various state insurance departments. Experience with auditing or accounting highly desired. Experience with MLR and related rebate requirements, or accounting/auditing in the healthcare, insurance, banking and/or Pharmacy Benefit Management (PBM) industries required. All work is expected to be completed remotely; no travel required. Specific Duties and Responsibilities Perform analytical reviews of documentation provided by companies supporting MLR calculations and distribution of rebates to enrollees for compliance with state and/or federal legislation. Perform attribute and accuracy testing of premium and claims transactions, and other major components of the MLR calculation to determine completeness and accuracy. Review Quality Improvement Activity (QIA) expenses, which are costs for activities that improve the quality of care provided to members, ensuring reported costs meet the definition of QIA and that intercompany allocations are fair and reasonable. Review Pharmacy Benefit Manager contracts and detail