Health Services Auditor Documentation Specialist

Intermountain Health • SelectHealth - Murray, GA

4d • $45 - $67 • Onsite

About The Position

Select Health is a community health plan serving more than 1 million members. Select Health’s line of businesses include Medicare, Medicaid, FEHB, Marketplace Qualified Health Plans, and fully funded and self-funded Commercial Employer plans. This position audits care delivery and documentation of care managers, utilization reviewers, and delegated entities on the execution of care and utilization management processes, policies, procedures, and guidelines to confirm they are completed in an effective and consistent manner; aligned with regulatory guidelines, recognized industry standards of practice, coverage benefits, and written service agreements to ensure the responsible provision of administrative and/or health care services to Select Health covered individuals and use of company financial resources.

Requirements

• Clinical Social Worker or Registered Nurse with current license to practice in the State of Utah.
• Bachelor’s degree in nursing (BSN) or master’s degree in social work (MSW) from an accredited institution. Degree will be verified.
• Two years of broad clinical care management or health insurance experience.
• Two years of audit-related experience in health care or data analysis.
• Experience requiring effective problem-solving, critical thinking, process analysis, and other strong analytical skills.
• Health Plans
• Clinical Documentation
• Computer Literacy
• Communication
• Organization
• Utilization Management
• Care Management
• Quality Improvement
• NCQA Standards
• CMS Guidelines

Nice To Haves

• Experience with health insurance, government programs (i.e., Medicare, Medicaid), or familiarity with accreditation bodies.
• Knowledge of Select Health products.

Responsibilities

• Utilizes audit tools, activity reports, and expert knowledge of the prevailing standards of practice, processes, policies, procedures, and regulatory guidelines related to care and utilization management to audit and oversee performance of Healthy Connections employees and delegated entities. This includes case file documentation, recorded phone conversations, application of medical criteria, adherence to policies, procedures, approved work processes, regulatory guidelines and expectations, and other aspects of medical management.
• Provides reports via professionally written deliverables to Healthy Connections management, Compliance Consultants, oversight committee(s), and delegated entities regarding findings from auditing and monitoring activities.
• Conducts and/or participates in focused audits as necessary including pre-delegation audits, program and regulatory audits, data and corrective action validation audits, and quality assurance reviews.
• Evaluates information identified in audits and oversight monitoring; and provides recommendations to the educator and/or Healthy Connections management team on areas for improvement at the individual caregiver and department level.
• Collaborates with team members to identify the need for changes to policies, procedures, and other work processes.
• Develops and maintains an audit tool and/or oversight monitoring processes that measure the efficacy and adherence of care managers and utilization reviewers to prevailing policies, procedures, and work processes.
• Measures the efficacy and adherence of delegated entities to their contractual obligations and service level agreements for the provision of care and utilization management services.
• Maintains an awareness of CMS, State Medicaid, and NCQA requirements related to health plan care and utilization management, and population health services.
• Establishes and maintains effective communications/professional relationships with delegated and prospectively delegated entities.

Benefits

• We care about your well-being – mind, body, and spirit – which is why we provide our caregivers a generous benefits package that covers a wide range of programs to foster a sustainable culture of wellness that encompasses living healthy, happy, secure, connected, and engaged.
• 100+ learning options to choose from, including undergraduate studies, high school diplomas, and professional skills and certificates.
• Caregivers are eligible to participate in PEAK on day 1 of employment.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level