CQM Nurse Auditor

Regal Medical Group•Los Angeles, CA

7d•$38 - $50

About The Position

The Continuous Quality Monitoring Nurse Auditor reports to the Manager of Continuous Quality Monitoring and performs utilization management (UM) process related quality monitoring to assure regulatory compliance and quality of process in daily utilization management activities with minimal to moderate supervision. The Continuous Quality Monitoring Auditor will work closely with the UM business units on elements that do not require clinical decisions to promote high quality, efficient and effective UM processes. This role also needs to support any projects directed by the Continuous Quality Monitoring manager. This position requires a progressive knowledge of comprehensive UM processes, policies & procedures, UM reports review, and quality improvement.

Requirements

Graduate from an accredited school for Nursing (LVN or RN).
Current and maintains California Nursing License.
At least 3 years of experience in managed care setting.
Minimum 2 years of utilization management experience in prior authorization and/or reporting.
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

Clinical license/experience preferred.
Minimum 1 year UM supervision or reporting audit experience, preferred.

Responsibilities

Continuous Quality Monitoring Auditor must be familiar with UM regulations and prior authorization processes.
Must be familiar with UM reports, be able to run certain reports using Report Manager and Tableau, as well as be proficient in excel and other report formats.
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.
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 assigned projects/quality monitoring audits are completed within required timeframe.
Collaborates with, and reports to UM compliance team, as needed, any compliance or HIPAA related deficiencies.
Reviews health plan case files and 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 directed by management.