Nurse Auditor - UM

Partnership HealthPlan of California•Fairfield, CA

About The Position

Under the direction of the Utilization Management (UM) Supervisor or above, this position will conduct audits of assigned areas, assist in department audit initiatives as well as perform audits in accordance with the department audit plan. As an integral member of the Training and Development Team, this position will help the audit function keep pace with the audit needs of the UM Department.

Requirements

Bachelor’s degree, licensure as a Registered Nurse in the State of California, or minimum five (5) years’ experience as a Registered Nurse preferably in a managed care and knowledge of Medi-Cal; or equivalent combination of education and experience.
Experience working with database systems.
Licensed as a Registered Nurse in the State of California
Proficient in computer applications such as Microsoft Word, Excel, PowerPoint and Visio.
Knowledge of managed care concepts, policies, and procedures.
Ability to understand, interpret, and prepare documentation related to regulatory requirements.
Ability to apply audit standards through practical application.
Proactive in researching utilization review and case management best practice concepts in order to apply as appropriate.
Great listening skills and ability to identify gaps in logic – inquisitive.
Strong organization and follow up skills including the ability to handle competing priorities and meet all deadlines and commitments.
Possess an appropriate combination of technical expertise in fields such as managed care, nursing, utilization management, and case management.
Ability to flourish in a fast-paced, complex environment and willing to adapt to change.
Ability to give and follow instructions accurately and efficiently; proactive in asking clarifying questions to ensure work effort is directed wholly toward desired outcome.
Ability to recognize when learned theoretical concepts should be applied.
Ability to work independently.
Basic understanding and ability to apply adult education standards when working to address audit results.
Developing the skills to identify underlying cause of an issue raised.
Good communication skills along with good or developing negotiation skills.
Willingness and ability to adapt to new circumstances, information, and challenges.
Executes effective and thorough application of all department audit standards within assigned responsibility.
Ability to use a computer keyboard.
More than 90% of work time is spent in front of a computer monitor.
When required, ability to move, carry, or lift reports, manuals, stocking of supplies, weighing up to 50 lbs.
Position includes frequent, repetitive motion including typing, sitting/standing for most of the day.
All HealthPlan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

Nice To Haves

Previous utilization management experience, including work with medical necessity criteria tools preferred.
Certification in Case Management Area Preferred.

Responsibilities

Performs assigned duties and tasks in accordance with department audit policies and standards.
Follows defined audit methodology, taking the initiative to continually improve execution and make improvement recommendations.
Identifies and acts on opportunities to use tools and techniques to improve quality and efficiency of audits.
Executes audit activities and constructs draft deliverables in a way that contemplates executive interest and reactions to observations; seeks coaching and information to develop an understanding of management’s viewpoints and expectations.
Proactively manages individual work assignments to meet schedule requirements.
Develops first drafts of issues, reports, and other deliverables.
Provides department leadership with recommendations regarding issue categorization/severity; provides recommendations regarding key messaging in audit reports.
Identifies weaknesses and gaps in department quality controls and elevated risk areas.
Drafts and communicates audit recommendations, individual staff reports and other written reports as needed.
Provides independent evaluations of documentation quality, staff and department productivity, operational and financial controls, regulatory compliance, and risk areas.
Performs and coordinates follow-up audits to determine if management has taken action to mitigate risks identified.
Assists in training and education opportunities to bring audit findings to leaders, staff, and other organizational stake holders.
Participates in special reviews as necessary.
Represents department audit’s goals, objectives, and viewpoints in collaborating with management and business constituents.
Drives department audit initiatives, special projects, and improvement initiatives, as assigned.
Provides input during all phases of risk assessment and annual audit planning and execution.
Applies industry standard audit procedures and documents findings in work papers in accordance with professional standards and department audit policies and standards.
Participates in meeting the objectives of the department audit training program; executes against agreed upon development goals.
Assists in defining initial engagement scope and objectives.
Documents audit work; designs initial audit work programs, testing strategies, and detailed testing procedures.
Performs reviews of assigned work paper sections, drafts audit reports, etc., as part of the quality assurance and improvement program.
Assists in collaborating with department leaders to fully understand their process and assists with getting to the root cause of identified deficiencies.
Assists in conducting regular presentations to business units to announce audit kickoff activities and to communicate audit findings.
Researches the topic to be audited and document/ catalogue regulatory and contractual standards governing each audit area.
Keeps abreast of company policies and procedures, current developments in managed care, utilization review/case management, and changes in state and federal laws and regulations, as applicable.
Mentors and educates seasoned and new staff with regards to department policies, practices, and operations.
May provide back-up to other positions as required.
Performs other duties as assigned.