Description: Judge Healthcare is currently seeking a Clinical Services Auditor to join our client's growing team in the Long Beach, CA area! This position is REMOTE but candidate must live in or near Long Beach.
Schedule: Monday to Friday, 8:30am to 5:30pm PST
This job will have the following responsibilities:
Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and/or Disease Management (DM) and monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
Audits for clinical gaps in care from a medical and/or behavioral perspective to ensure member needs are being met.
Assesses clinical staff regarding appropriate clinical decision-making. • Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings leadership.
Ensures auditing approaches follow a Molina standard in approach and tool use.
Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications.
Adheres to departmental standards, policies, protocols.
Maintains detailed records of auditing results.
Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.
15% travel required.
Qualifications & Requirements:
Bachelor's or Master's Degree in a social science, psychology, gerontology, public health or social work.
Must have an LVN or RN (CA State license)
Must have at least two years of experience in Utilization Management (UM)
One year of auditing/ clinical review experience preferred
Two years CM, MAT, HM, DM, and/or managed care experience preferred.
If you or someone you know is interested in this position, please send a current resume to Kelly at kjackson@judge.com or 214-281-5947
Contact: kjackson@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com
