Clinical Data Audit Consultant

Centene Corporation•Remote-CA, NV

22h•$34 - $61•Remote

About The Position

This role is for a clinical professional on the Medical Management/Health Services team. The Clinical Data and Audit Consultant is responsible for the clinical content component of all data collection, account implementations, and audit activities for Clinical Operations to ensure high-quality tracking and performance of the service teams. The Consultant gathers and analyzes data, creates workflows, coordinates internal and external audits, and analyzes and documents business processes to meet all clinical, procedural, account, and regulatory requirements.

Requirements

Licensed Clinician and/or RN required.
Must have and maintain current, valid and unrestricted clinical license.
BA/BS in Psychology, Nursing or other related clinical field
Three to five years case management or related clinical experience
Two to three years experience conducting business studies, recommending solutions and/or business analysis, preferably in Healthcare

Nice To Haves

Masters in Social Work, Counseling, Nursing, or related field preferred

Responsibilities

Leads various data analysis projects to examine and define potential clinically related issues and track productivity and quality measures
Reviews, analyzes, and interprets data for required HEDIS, URAC, NCQA compliance, and related reporting for clinical service teams
Interprets clinical data that does not conform to established/approved, required specifications, including Unity Reports, and assists in corrective action processes
Addresses and participates in training of clinical staff resulting from data tracking and analysis efforts
Identifies, evaluates, recommends and documents clinical business needs and objectives, operational processes and procedures, problems and requirements
Produces documentation, including project plans, analytical reports, decision backup, information research reports, training plans, business justifications, graphics, workflow and business process models
Recommends operational and process improvements based on efficiencies and available technologies
Maintains a repository of performance and audit metrics, and generates management reports illustrating statistical data, text, workflows, and graphics
Conducts secondary research using a variety of publications, services and health statistic databases
May also be assigned lower level management functions and back up supervisors on clinical team
Works with other departments to identify and document business requirements, workflow, policies and procedures
Organizes and compiles cases for all External Health Net, NCQA, URAC, and Account Audits
Participates in Quarterly Health Net Regulatory Audit meetings to assist Clinical Directors
Supports Clinical Supervisors in tracking of monthly Care Manager audit results
Works with Data Analysis Department to design data pulls
Assists with generating HLOC and Outpatient Cost of Care and Target Outlier Reports including trend analysis
Supports staffing analysis with current and forecasted requirements
Investigates current regulations, interprets findings, and makes recommendations to Healthcare Services teams
Conducts complex trend analysis and, based on analysis, creates Corrective Action Plans, and presents recommendations to business teams across department to improve performance
Performs other duties as assigned
Complies with all policies and standards