Overview:
About us:
Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.
Brief summary of purpose:
The Internal Audit Department (IA) at Fallon Health is committed to protecting Fallon Health by conducting independent and objective internal audits and assessments of its operational, financial and compliance controls. IA reports administratively to the Chief Compliance Officer and functionally to the Audit & Compliance Committee and plays a key role in auditing risks identified in the organization. The Senior Internal Auditor plays a key role in implementing the annual audit plan. The Senior Internal Auditor conducts audits and related projects (financial, operational, and regulatory in nature), documents and conveys results and makes recommendations. This position requires a professional with strong analytical, technical, and communication skills, as well as a desire to work in a collaborative environment with the ability to interact with all levels of the organization.
Responsibilities:
The Senior Internal Auditor will work under the direction of the Audit Director or Audit:
- Assist with the assessment of operational, financial and compliance risks, and controls, and policies and procedures in all Fallon Health business units and other subsidiaries.
- Assist management on audits, projects, as well as special requests. This could include the completion of claims, operational, financial and compliance audits, as well as, testing of internal controls (Model Audit Rule).
- Perform all aspects of audits following departmental standards and procedures, including walkthrough of processes, setting objectives, defining scope, designing tests, and performing the audit testing. This includes conducting compliance audits to assess the adequacy of compliance with applicable regulations, laws, and standard operating procedures (including CMS).
- Analyze audit evidence to provide management with an evaluation of the adequacy of financial, operational, and regulatory controls and make recommendations for improvement. This could include claims testing for payment accuracy and financial accuracy.
- Communicate effectively with all levels of management to ensure full understanding of objectives, risks, controls, and observations.
- Prepare clear and concise audit reports, corrective action plans, and other communications.
- Complete ad hoc projects as requested by management.
- Attend and participate in workgroups, committees, or projects.
- Research potential fraud, waste or abuse related inquiries.
Primary Job Responsibilities:- Assist in the development of the annual Internal Audit Plan, including areas such as Compliance, IT and Care Services.
- Develop audit programs to identify areas of risk to be addressed, and detail the steps to be taken, including evaluating compliance risks with all pertinent federal, state, and local regulations and standards.
- Plan and conduct scheduled and non-scheduled audits according to the audit plan and budget.
- Perform an evaluation to ensure all aspects of the audit are following departmental standards and procedures.
- Oversee and direct audit staff assigned to the audit and provide Audit Management with periodical updates and status reports.
- Evaluate the adequacy of financial, operational and regulatory controls and testing for compliance with all pertinent federal, state and local regulations and standards.
- Evaluate the areas of risk to be addressed for each audit and perform a risk assessment (before and after testing).
- Test the internal controls and data for proper documentation.
- Review compliance with existing policies and procedures by performing the required audit steps.
- Prepare audit reports based on audit findings derived from and supported by the audit work papers.
- Appraise, or assist in appraising, the adequacy of the corrective action taken to improve deficient conditions.
- Document procedures and findings in all the test areas.
- Provide recommendations requiring management responses to address the identified findings.
- Conduct audit exit meetings to review audit report findings.
- Make recommendations for process improvements as needed.
- Assist with the validation of divisional self-monitoring audit results.
- Serve as resource to business unit compliance officers.
- Provide regular status updates to Internal Audit Management.
- Identify and escalate critical issues to Internal Audit Management as appropriate and as directed.
Qualifications:- Education: Bachelor’s degree is required, preferably in Business Administration with a concentration in Finance/Accounting or equivalent work experience. Master’s degree a plus.
- License/Certifications: Certified Internal Auditor (CIA), a plus or other equivalent certification, a plus.
- Required Skills and Experience:
- Minimum of 4-5 years of internal audit experience or relevant work experience working in corporate environment, preferably in health care, financial and/or insurance industry.
- At least one-year experience in a Sr. Auditor capacity.
- Information Technology auditing experience, a plus.
- SOX or Model Audit Rule (MAR) audit/financial experience, a plus.
- The ability to communicate orally and in writing to individuals and groups from varied disciplines and levels of management.
- Excellent analytical, problem solving, organizational skills required.
- Project management skills, a plus.
- Personal tenacity, team leadership skills and the ability to foster change.
- Strong computer skills with proficiency in Microsoft Office applications.
- Ability to travel as necessary 5% to 10%.
- Other Professional certification (CPA or CIA), a plus or be willing to pursue a professional certification.
Key Competencies, Skills, and Key Success Factors:- Must have high degree of self-motivation and excellent judgment.
- Comfortable working in a fast-paced environment and can readily adapt to changes within the organization or department.
- Ability to conduct risk assessments and perform root cause analysis.
- Highly effective written and oral communication skills with the ability to communicate audit results and finding to all levels of the organization, including Executive Leadership.
- Possess a strong level of accountability.
- Ability to work independently and part of a team, including serving as the team lead when necessary or assigned.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
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