Medical Management Auditor

Centene

117d • $55,100 - $99,000 • Remote

About The Position

Responsible for the auditing of corporate, health plan, and specialty company staff related to clinical systems entry and/or processes. Develop and maintain the audit process and tools related to: authorizations, appeals, quality events, and case management in CCMS; interrater reliability related to InterQual; and data entry into the credentialing subsystem. Develop and maintain the audit schedule. Audit staff as outlined in the system auditing policies. Train audit staff at the health plan in the use of audit process and tools. Facilitate compliance with the auditing process. Act as a consultant related to system auditing to others in the unit, department and health plan. Work with staff to identify and resolve authorization load error report system problems. Coordinate auditing outcomes with the Trainer to identify, develop and publish corrective actions/educational material related to audit errors. Coordinate auditing outcomes and system maintenance with the Sr. Clinical Systems Specialist to resolve or enhance clinical systems. Performs other duties as assigned. Complies with all policies and standards.

Requirements

• Bachelor's degree in related field or equivalent experience.
• 3+ years of related experience.
• For Home State Health Plan only: State unrestricted license as Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Registered Nurse (RN), or Licensed Practical Nurse (LPN).

Nice To Haves

• Licensed Practical Nurse (LPN) preferred.

Responsibilities

• Auditing corporate, health plan, and specialty company staff related to clinical systems entry and/or processes.
• Developing and maintaining the audit process and tools related to authorizations, appeals, quality events, and case management in CCMS.
• Maintaining the audit schedule.
• Auditing staff as outlined in the system auditing policies.
• Training audit staff at the health plan in the use of audit process and tools.
• Facilitating compliance with the auditing process.
• Consulting related to system auditing to others in the unit, department, and health plan.
• Identifying and resolving authorization load error report system problems.
• Coordinating auditing outcomes with the Trainer to develop and publish corrective actions/educational material related to audit errors.
• Coordinating auditing outcomes and system maintenance with the Sr. Clinical Systems Specialist.

Benefits

• Competitive pay
• Health insurance
• 401K and stock purchase plans
• Tuition reimbursement
• Paid time off plus holidays
• Flexible approach to work with remote, hybrid, field or office work schedules

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree