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Clinical Auditor, Case Management/Utilization Management Review

Company: Amerihealth
Location: Philadelphia
Posted on: November 22, 2021

Job Description:

Your career starts now. We're looking for the next generation of health care leaders.At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at a member of the Corporate Clinical Auditing team, the Clinical Auditor coordinates and completes associate quality audits of clinical staff, focused reviews, and problem identification. Provides coaching and feedback to associates as necessary. Provides routine/scheduled and ad hoc audit reports, including trend identification and root cause analysis. Coordinates development of action plan for identified issues. Participates and assists in the development of necessary protocols, policies and procedures, and operational strategies for Clinical Services. Provides a report tracking compliance with timeliness as mandated by applicable legislative and accrediting organizations, including trend identification and root cause analysis. Coordinates development of action plans for identified issues. Responsible for ongoing development of audit tools to meet business needs. Participates in Quality Reviews and Inter Rater Reliability process as requested. Works with the management team to develop and provide individual and department-level performance improvement plans and activities as well as plan/process follow-up.Additionally, the Clinical Auditor will interface with delegated provider groups, complete required auditing and reporting related to provider/subcontractor delegation, and ensure adherence with NCQA , state and business requirements. Serves as a key contact for delegated provider groups, ensures compliance with established contract, and monitors provider/subcontractor performance. Specific responsibilities and tasks may vary based on area within Corporate Quality and Accreditation, Medical Excellence (outlined below).In addition to the following responsibilities, the Clinical Auditor will manage the pre-delegation and annual delegation audit to include auditing for clinical related activities such as utilization management and care management and appeals functions. Assessments will include auditing of clinical activities performed by the delegates. Will ensure compliance with NCQA and State/federal regulations from a clinical perspective.

  • Supports Delegation Oversight across the multiple lines of business and business products;
  • Supports implementation of new subcontractor and/or new LOB to existing subcontractors by facilitation of meetings, contract requirements analysis and the interface of multiple departments and subcontractors
  • Assist with creating supporting clinical auditing tools for internal or external auditing.
  • Conducts external pre-delegation and annual audits for new and existing delegated entities for the following areas: Utilization Management, Care Management, Quality Management, and Appeals.
  • Provides clinical expert knowledge and guidance internally and externally around delegation oversight requirements and standards.
  • Conducts contract analysis for subcontractor/provider contracts to identify gaps and opportunities.
  • Conducts state's contract analysis (RFPS, AHCA Contract, CMS Manage Care Manual) across all lines of business to ensure plan delegation oversight compliance elements are met for all clinical functions.
  • Documents, evaluates and validates regulatory compliance with all requirements of all regulatory agencies including, but not limited to, AHCA, CMS, URAC (when applicable) and NCQA.
  • Ensures subcontractor performance standards are met in accordance with agreement/SOW and regulatory requirements.
  • Collects and summarizes performance data, identifies opportunities for improvement, and presents to the Delegation Coordinator.
  • Participates in site visit preparation (when needed) and execution (readiness reviews prep and interviews) by regulatory agency and accreditation agencies when necessary.
  • Maintains all documentation to support evidence of compliance with all delegation requirements.
  • Assist in managing policies and procedures relating to Delegation Oversight.
  • Assist with Quality Committee activities.
  • Report audit outcomes and delegation monitoring results to management.
  • Responsible for recommending Corrective Action Plans and/or Performance Improvement Plans, when needed.
  • Travel requirement: approximately 25%.Education/Experience:
    • Associate's Degree. Bachelor's Degree.
    • Current and unrestricted Registered Nurse licensure OR Master's Degree (Master Level Clinician) preferred.
    • 1-2 years of specific clinical knowledge / experience in Utilization Management and/or Case Management.
    • 3-5 years of credentialing, delegation, or relevant provider data experience preferred.
    • Working knowledge of EXP, SIR, Jiva, and Microsoft Office (Word, Excel, Outlook) desired.
    • Strong working knowledge of clinical criteria - InterQual preferred.
    • Demonstrated knowledge of plan benefit information and managed care.
    • Demonstrated critical thinking and problem solving skills to identify trends and conduct root-cause analyses to help ensure successful delegation partnerships and department quality.
    • Excellent verbal and written communication skills, including the ability to present to small groups as well as to provide constructive feedback with a focus on improved quality.
    • Ability to follow detailed instructions with a high degree of accuracy. Along with a strong ability to create, monitor, and analysis provider data.
    • Ability to work independently; complete tasks in the allotted time frame, and represent the company in a professional manner.
    • Ability to prioritize and manage multiple tasks/priorities simultaneously..
    • Current state driver's license and car insurance.Back ShareApply Now

Keywords: Amerihealth, Philadelphia , Clinical Auditor, Case Management/Utilization Management Review, Executive , Philadelphia, Pennsylvania

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