Clinical Auditor, Case Management/Utilization Management Review
Posted on: November 22, 2021
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
www.amerihealthcaritas.com.Responsibilities:As 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
- 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
- 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
- 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
- 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
- Assist with Quality Committee activities.
- Report audit outcomes and delegation monitoring results to
- 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
- Demonstrated knowledge of plan benefit information and managed
- 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
- Ability to prioritize and manage multiple tasks/priorities
- Current state driver's license and car insurance.Back
Keywords: Amerihealth, Philadelphia , Clinical Auditor, Case Management/Utilization Management Review, Executive , Philadelphia, Pennsylvania
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