The Clinical Auditor will conduct routine oversight, monitoring and auditing of externally delegated functions to ensure compliance with state, federal, and accreditation standards.
POSITION RESPONSIBILITIES:
- Independently manages multiple concurrent and retrospective audits, monitors efforts, and related projects; makes recommendations around objectives and scope of regulatory adherence and ensures effective and efficient audit execution.
- Researches regulations and informs delegates of any changes to regulatory requirements.
- Conducts mock audits of delegated clinical functions using audit tools and develops corrective action plans to address any identified issues.
- Performs readiness and annual oversight audits for applicable areas ensuring the entity’s ability to perform activities; prior to contract execution and in accordance with the agreement.
- Collects and summarizes performance data and presents findings to all applicable committees.
- Participates in workgroups that address both clinical and non-clinical activities for which CalOptima must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS), California Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC), and any other applicable entity.
- Serves as Subject Matter Expert (SME) for clinical and quality areas.
- Participates in the Audit & Oversight Committee and ad hoc escalation meetings, when necessary.
- Other projects and duties as assigned.
Required Skills
- Work independently, while having excellent time management and organization skills to be able to; prioritize, manage multiple tasks, and have strong attention to detail.
- Organize and administer complex project plans to achieve organizational and departmental goals and objectives.
- Demonstrate and motivate others in effective team coordination and cooperation.
- Establish and maintain effective working relationships with staff, at all levels, other programs, agencies and the public.
- Formulate, understand and interpret policies, procedures and regulations.
- Utilize and access computers and appropriate software (e.g. Microsoft Office applications) and job-specific applications/systems.
Required Experience
EXPERIENCE & EDUCATION:
- Bachelor’s degree in Health Sciences, Public Health, Health Administration, Nursing or other related field; or equivalent combination of education and work experience required.
- Minimum current, unrestricted LVN license to practice in the state of California is required, RN preferred.
- 2 years of experience in utilization management or equivalent experience required.
- 1 year of experience in a health care delivery system, including health plan, medical group, or hospital management preferred.
- Approved means of transportation needed to perform reviews away from the primary office 10% of the time.
KnOWLEDGE OF:
- Legislative, regulatory and utilization management and quality requirements for health care service delivery to beneficiaries of the following programs: Medi-Cal, Cal MediConnect, and Medicare.
- Managed care compliance for Medi-Cal and Medicare.
- Principles and techniques of project management to ensure that numerous goals, objectives and detailed actions are properly identified, and their status monitored.
- Principles and practices of managed health care, health care systems, and medical administration.
- Clinical criterial application/sources and utilization management processing of prior authorization requests, as well as retrospective and concurrent requests.
Grade: M
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