Manager Clinical Auditing

Amerihealth Caritas•,

5d•Remote

About The Position

Under the direction of the Director, Corporate Clinical System Administration, Training, and Auditing, the Manager of Clinical Auditing is responsible for day to day operations of the clinical audit team. In this role, you will have oversight of a team of clinical auditors responsible for monthly audits of associates in utilization management, appeals, case management, rapid response, and appeals as well as the audits of external vendors. The Manager of Clinical Auditing focuses on audit consistency, corrective action planning, and executive level reporting, while partnering with all levels of leadership, Medical Directors, and training teams to drive quality improvement.

Requirements

Associate's Degree in Nursing.
Minimum of 3 years of diverse independent clinical practice experience
Minimum of 3 years of utilization management and/or case management experience in a managed care organization
Experience applying NCQA regulatory standards to ensure 100% compliance with clinical file review standards
Experience executing oversight audits to verify subcontractor compliance with NCQA standards, identifying documentation gaps and implementing Corrective Action Plans (CAPAs) in collaboration with compliance and legal teams
Experience applying standardized clinical criteria such as InterQual (preferred) to evaluate medical necessity and appropriate level of care
Experience leading a remote team of licensed clinical professionals
Experience presenting to external agencies and/or leadership teams the EQRO (External Quality Review Organization) process and clinical auditing team operational processes
Active and unencumbered Registered Nurse license in all states of licensure
Strong working knowledge of clinical criteria, InterQual preferred
Demonstrated working knowledge of plan benefit information and managed care, specifically Medicare and Medicaid
Ability to design and deliver presentations to internal and external stakeholders with confidence and clarity
Demonstrated ability to design, implement, and manage organizational processes that optimize efficiency and ensure accuracy without relying on automated tools
Proactive problem-solver with demonstrated ability to manage and resolve high priority escalations
Proficiency using Healthcare Management Platforms and all components of MS Office with speed and accuracy

Nice To Haves

Bachelor's Degree preferred
Experience applying standardized clinical criteria such as InterQual (preferred) to evaluate medical necessity and appropriate level of care
Strong working knowledge of clinical criteria, InterQual preferred

Responsibilities

Oversee the quarterly clinical auditing process, inclusive of associate quality audits, focused audits, ad hoc audits and comprehensive timely reporting of the results
Participates and assists in the development of protocols, policies and procedures
On-boards new business/teams to clinical auditing process
Coordinates the development of action plans for identified issues
Ongoing management and maintenance of the audit database and audit tools
Conducts quality reviews and inter-rater reliability (IRR) testing of clinical auditors
Works with management teams to develop individual and department level performance improvement plans and activities as needed