Seeking a Senior Clinical Program Auditor RN for a 100% Remote position.

The primary role of the Senior Clinical Auditor is to evaluate the effectiveness of Clinical business processes, management, and controls. Additionally, the key functions include: consulting related to process improvement, strengthening controls which directly impacts internal efficiencies and Compliance adherence (i.e. CMS, NCQA). This role requires in depth clinical (i.e. MCG, Interqual, LCDs), and process knowledge in Utilization Management, Case Management, Billing and Coding, and Claims business areas. This role is responsible for interacting directly with internal and external Senior Leadership and executives (Senior Managers, Directors, etc.) of various business areas (including State Accounts, FEP, etc.).

Essential functions

• Design and administer audit programs which meets the clients’ business needs (Utilization Management, Case Management, Disease Management, Payment integrity Office, and other business areas)
• Evaluating the Health of the business through assessments over the effectiveness of business processes and controls to include the following:
  Identification of risks and control/process gaps through root cause analysis within the current business processes
• Oversight of the Clinical Audit process improvement and corrective action plans
• Monitoring and identification of trends through data analysis which drive process efficiencies and improve compliance adherence
• Collaborate with Medical Directors, Managers, Sr. Managers, Peers, and internal staff
• Participate in Improvement Projects

Required Experience

• 5+ years related work experience - Managed Care and clinical audit and/or related experience
• Experience with NCQA UM and PHM standards
• Experience with Interqual and Medical Coverage Guidelines
• Expert Level experience with Excel and Microsoft Office Suite
• Excellent communication skills, both written and verbal
• Experience in Case Management/Complex Case Management, Clinical Training/Education
• Experience with National Committee for Quality Assurance (NCQA) survey audit preparation
• Experience developing and/or conducting documentation audits for Clinical/Quality Documentation Audit Program

Qualifications/Certificates:

• Registered Nurse
• State Licensure And/or Compact State Licensure