Population Health Management Clinical Auditor and Trainer RN I

KHS•Bakersfield, CA

3d•$45 - $57•Onsite

About The Position

Under the direction of the Case Management Manger, the CM Clinical Auditor and Trainer is responsible for reviewing Case Management (CM) Clinical documentation and guidelines to ensure staff compliance with established processes. Perform audits on Nurse Case Managers and Social Worker Case Managers for compliance. Responsible for reporting findings to management for review and possible corrective action. Provide recommendation for process improvement and assist with action plans for making those corrections. The Clinical Auditor and Trainer will work in a coordinated effort with the Case Management Manager and Business Analyst to ensure smooth, efficient and productive operations within the Population Health Management Department, as directed by the Director of PHM Management. Distinguishing Characteristics This position will provide technical and clinical support to a Knox-Keene licensed health maintenance organization (HMO) Population Health Management Department. The purpose of this position is to provide support to the Population Health Management team for compliance and report generation, data collection, and analyses for interpretation and presentation to the KHS Executives and Board of Directors. Training for all on-boarding of clinical staff and development of defined and prescribed processes for staff improvement in addition to providing one-on-one training to improve staff efficiencies will be the major focus of the position.

Requirements

Lead by example to support a positive work environment that values patient advocacy, respectful listening, diverse expression of opinion and constructive conflict resolution:
Represent KHS in a positive manner to all members, caregivers, staff and external stakeholders
Demonstrate commitment to continuous improvement
Strong knowledge of acute chronic care nursing principles, methods and common treatments
Strong knowledge of common human diseases and usual and customary methods of treatments
Demonstrated knowledge of medical terminology
Ability to effectively evaluate medical records to determine appropriateness and necessity of care
Demonstrated knowledge of health care delivery systems
Very strong interpersonal skills, including the ability to establish and maintain effective working relationships with individual at all levels both inside and outside of KHS
Ability to use tact and diplomacy to diffuse emotional situations
Effective oral and written communication skills, including the ability to effectively explain complex information and document according to standards
Intermediate skills in Word and Excel with basic ability to enter data into and navigate through a database
Demonstrated ability to respect and maintain the confidentiality of all sensitive documents, records, discussions and other information generated in connection with activities conducted in, or related to, patient healthcare, KHS business or employee information and make no disclosure of such information except as required in the conduct of business
Demonstrated ability to commit to and facilitate an atmosphere of collaboration and team work
Self-directed, with proven ability to work independently with minimum supervision
Demonstrated ability to multi-task in an interrupt-driven environment and complete assignments on a timely basis
Strong attention to detail
Registered Nurse (RN) with an active, current, unrestricted license required.
Minimum of two years (2) full-time clinical nursing experience in acute care, community health setting, public health nursing or chronic disease management required
Experience working with patients and caregivers regarding self-care and disease management required
Valid California Driver License and proof of state required auto liability.
Up to 5% driving

Nice To Haves

Experience working in case management or care coordination is a plus
Knowledge of Kern County Community resources for seniors and people with disabilities is a plus
Bilingual preferred.

Responsibilities

Design and deliver training programs for clinical staff on healthcare best practices, NCQA standards, and departmental policies.
Provide ongoing education and support to staff on clinical processes, care management systems, and documentation standards.
Ensure all training content is aligned with NCQA guidelines, DHCS requirements and current industry standards.
Conduct orientation and refresher courses for new and existing employees, ensuring competency in NCQA-compliant processes.
Assess the effectiveness of training programs and modify content as necessary based on feedback and performance evaluations.
Conduct audits of clinical documentation, care management workflows, and case management processes to ensure compliance with NCQA standards and departmental policies.
Provide feedback to staff on audit findings, offering guidance on how to improve deficiencies and maintain compliance.
Collaborate with management and supervisors to develop action plans for addressing audit findings and process improvements.
Monitor the implementation of corrective actions following audits to ensure continual improvement in clinical practices.
Prepare detailed audit reports, documenting findings, recommendations, and progress toward corrective actions.
Apply a strong understanding of NCQA standards and requirements to both training and auditing functions.
Ensure that the organization maintains NCQA accreditation and that all staff are informed of and compliant with NCQA guidelines.
Stay current with changes to NCQA requirements and implement updates to training materials and auditing processes as needed.
Participate in quality improvement initiatives by contributing to the development and implementation of strategies for improving care delivery and operational efficiency.
Track performance metrics related to training and compliance, and report outcomes to management.
Assist in developing and monitoring key performance indicators (KPIs) for staff training and audit activities.
Maintains knowledge of all processes in the Population Health Management Department.
Shares information as necessary with appropriate CM Clinical Staff.
Maintain an effective, efficient, and confidential filing system both manual and electronic to allow easy retrieval and re-filing of department information.
Case manages a case load to keep updated and monitor workflow for clinical staff.
Adheres to all company policies and procedures related to employment and job Responsibilities.
Maintains the confidentiality of records and reports for both the membership of KHS and the contract providers.
Performs other job-related duties as required