Grievance and Appeals Internal Auditor

About the role

The Internal Auditor is an important position to ensure quality case investigations within the Grievance & Appeals Department (G&A). The auditor assesses the quality of all grievance and appeal cases to ensure they meet DHCS-mandated requirements, NCQA specifications, and Partnership professional standards.

Responsibilities

• Regularly conducts concurrent and retrospective audits of individual case investigations according to established audit criteria and provides feedback to associates as applicable
• Performs routine and timely quality assurance audits for all types of cases – grievance, appeals, exempts, and State Hearing cases conducted on a standard or expedited basis
• Assesses cases to determine if DHCS-mandated timeframes, NCQA specifications, and Partnership professional standards for member experience are met
• Determines if clinical guidance is executed accurately throughout the case investigation process
• Evaluates the quality of written communications
• Assesses accurate use of reporting fields to support DHCS, NCQA, and interdepartmental reporting interests
• Evaluates the appropriateness of referrals and determine if best resolution is offered given nature of case
• Enters audit findings of individual cases in the audit tracking database
• Provides audit findings feedback to G&A Manager and Supervisors regarding associates' audit performance
• Keeps current on all regulatory requirements that may influence G&A audit criteria and/or practices
• Recommends areas in need of additional training and/or close oversight based on the trending and analysis of audit results
• Makes strategic recommendation(s) to improve the accuracy, quality, and/or reporting of case investigations based on audit observations in order to enhance members' healthcare experience
• Assists in the development and maintenance of auditing guidelines, including the audit tracking database
• To support regulatory compliance, creates and maintains desktop(s) to document policy and procedures for G&A audit practices
• Maintains strict confidentiality of members' PHI/PII
• May participate in special projects or initiatives as directed

Qualifications

• Bachelor's degree in a health or business related field preferred; two (2) years of experience with grievance, appeal, and State Hearing cases or equivalent combination of education and experience
• Experience with medical criteria used to determine approval of medications, services, or referrals desired (e.g., TAR, RAF)
• Very detailed oriented, excellent writing and communication skills
• General knowledge of managed care and Medi-Cal benefits desired
• Experience in managed care business practices and the ability to access data information using computer systems
• Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines
• Strong organizational skills required
• Effective telephone, computer and, data entry skills required
• Valid California driver's license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business
• Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications are required
• Ability to understand and ensure compliance with established criteria and protocols used in managed care functions
• Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses
• Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers
• Self-driven and works independently

Work environment and physical demands

• Heavy use of the computer for most of the day
• Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs
• All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan's policies and procedures, as they may from time to time be updated

Pay

HIRING RANGE: $42.38 - $52.97