Clinical Auditor

Responsibilities

• Coordinates and completes associate quality audits of clinical staff, focused reviews, and problem identification.
• Provides coaching and feedback to associates as necessary.
• Provides routine/scheduled and ad hoc audit reports, including trend identification and root cause analysis.
• Captures and summarizes performance data, identifies opportunities for improvement, and presents to the Delegation Coordinator.
• Maintains all documentation to support evidence of compliance with all delegation requirements.
• Conducts external pre-delegation and annual audits for new and existing delegated entities for the following areas: Utilization Management, Care Management, Quality Management, and Appeals.
• Documents, evaluates, and validates regulatory compliance with all requirements of all regulatory agencies including, but not limited to, AHCA, CMS, URAC (when applicable) and NCQA.
• Ensures subcontractor performance standards are met in accordance with agreement/SOW and regulatory requirements.
• Participates in Quality Committee activities.
• Reports audit outcomes and delegation monitoring results to management.
• Responsible for recommending Corrective Action Plans and/or Performance Improvement Plans, when needed.

Requirements

• Bachelor’s Degree
• 1 to 2 years of specific clinical knowledge / experience in Utilization Management and/or Case Management
• 3 to 5 years of credentialing, delegation, or relevant provider data experience preferred
• Active and unrestricted RN License preferred
• Strong knowledge of clinical criteria – InterQual preferred
• Demonstrated knowledge of plan benefit information and managed care
• Strong problem solving skills and decision making skills

Skills

• Strong knowledge of clinical criteria – InterQual preferred
• Demonstrated knowledge of plan benefit information and managed care
• Strong problem solving skills and decision making skills

Benefits

Our Comprehensive Benefits Package includes flexible work solutions including remote options, hybrid work schedules, competitive pay, paid time off including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.