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

The primary role of the Clinical Auditor is to evaluate the operational effectiveness of clinical-decision making, business processes, management, and related internal controls. Additional key functions include: identifying process deficiencies and gaps which directly impact internal departmental efficiencies as well as regulatory and accreditation requirements (CMS, NCQA). This role requires general clinical, system, and business process knowledge related Utilization Management, Case Management, Billing and Coding, and Claims areas. This role is responsible for interacting directly with internal and external Management within the various business areas.

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

Qualifications

• Experience in one or more of the following: Utilization Review , Complex Case Management, National Committee for Quality Assurance (NCQA)
  survey audits, Training
• Experience with the health insurance industry (Managed Care)
• Experienced in MS Word and Excel
• Occasional travel within the State of Florida
• Experience in technical writing , i.e. Audit Findings Reports, SOPs, and Desktop Procedures
• Experience/knowledgeable of internal documentation applications, i.e. Jiva, Diamond
• Experience developing and/or conducting documentation audits for Clinical/Quality *Documentation Audit Program

Experience:

• 2+ years related work experience (Clinical experience in a hospital setting)
• Experience with NCQA Utilization and Case Management/Complex Case Management standards

Qualifications/Certificates:

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