CQM Non-Clinical Auditor

Regal Medical Group•Los Angeles, CA

1d•$30 - $32

About The Position

The Continuous Quality Monitoring (CQM) team is responsible for ensuring regulatory compliance related to Utilization Management (UM) and Case Management (CM) activities. The CQM auditor reports directly to the CQM Manager. CQM duties include, but are not limited to, performing UM process related internal audits, coordinating Health Plan corrective action responses with the responsible business units, pre-audit preparation for health plan audits, and active involvement in other tasks as assigned by the Continuous Quality Monitoring Manager. The position also requires a thorough understanding of comprehensive UM processes, policies, procedures, report reviews, and quality improvement initiatives. Other traits that are essential for success in this role include a strong work ethic, perseverance, initiative, excellent communication skills, accountability, and comfort in a highly computerized environment.

Requirements

Graduate from 4 years University with bachelor diploma, preferred.
At least 3 years of experience in managed care setting with minimum 2 years of UM experience in prior authorization.
Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point).
Typing 60 words per minute with accuracy.
Ability to deal with responsibility in confidential matters.
Must have strong analytical, creative problem solving, and organizational skills.
Ability to work in a multi-task, high stress environment.
Ability to strategize effectively, execute with timeliness, and deliver quality results.
Ability to thrive in a fast-paced environment where flexibility and being proactive are essential.
Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
Must have the ability to work with all levels of management and have the ability to develop positive working relationships with different divisions in the company.
Must possesses strong verbal & written communication skills.

Nice To Haves

Minimum 1-year of UM supervision or reporting audit experience, preferred.

Responsibilities

Must be familiar with UM regulations and prior authorization processes, as applicable to all lines of business including EAE DSNP, Commercial, Senior, Medi-Cal, etc.
Must be familiar with UM reports, be able to run certain reports using Report Manager and Tableau.
Must be proficient in excel and other report formats.
Review, distribute, draft, provide feedback and follow through completion on assigned Health plan specific CAPs.
Perform pre-health plan audit file reviews in preparation for health plan audits.
May drive/present case files during external audits.
Assigned specific UM process related quality audits which vary in number and audit elements.
Summarizes quality monitoring audit findings and works with the business units to obtain remediation for identified deficiencies.
May also analyze root causes and propose quality improvement plans (as applicable).
Maintain, file, and track automated reports received and internal audits performed.
Maintain, file, and track health plan CAPs and NON-CAPs.
May prepare and conduct focus monitoring on specific areas needing improvement based on quality monitoring findings, health plan audit results, and/or executive management requirements.
Ensures all assignments are completed within required timeframe.
Ensures all health plan tasks are submitted by the due date with 100% compliance.
Collaborates with, and reports to UM compliance team, as needed, any compliance or HIPAA related deficiencies.
Reviews health plan case files pulled by the liaison team and health plan reporting to ensure HIPAA compliance.
Works with business units to monitor the effectiveness and efficiency of any process changes made for quality improvement.
Ensures the implementation of new processes to incorporate updated policies & procedures are implemented accurately through reports and case file reviews.
Maintains the Continuous Quality Monitoring manager informed of all completed assigned audits, any non-compliance identified during audit review, etc.
Maintain abreast of all applicable policies and procedures and job aids to ensure a minimum accuracy rate of 95% in all assigned auditing.
Maintain continuous quality monitoring department resources and tools updated based on current policy and procedure and job aids.
Keep evidence of all quality monitoring audits, assignment, remediation, and projects.
Maintain organized and updated departmental folders, grids, etc.
Works with UM business units, under direction from the continuous quality monitoring manager, to monitor UM employee processing performance.
Attend department meetings, in-services, trainings, and complete acknowledgement within required timeframe.
Other duties as assigned.