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Healthcare - Clinical Services Auditor

Company: APN Consulting
Location: Long Beach
Posted on: August 3, 2022

Job Description:

Job DescriptionPosition: Clinical Services AuditorREMOTE/Hybrid (Long Beach, CA)Duration: 3 MonthsJob Description:The position is mostly remote, but there will be an onsite requirement for candidates to report a few times a month to the Long Beach office. Please ensure candidates are local to Long Beach, CA.Candidates must have UM experience. Manager DOES NOT want to see resumes with only case management or quality management experience.A strong candidate will have experience processing referrals which differs from candidates who have experience working at the hospital receiving referral request.The referrals will be mostly for Outpatient Professional Services.Potentially will be temp to hire and may transition to an onsite role once Client's offices reopenThis person will be conducting/monitoring audit activity to review Utilization Management (UM) decisionsMust 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.Schedule: Monday to Friday, 8:30am to 5:3pm PSTKnowledge/Skills/Abilities---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 Client 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.- Meets minimum production standards- May conduct staff trainings as needed---Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them.---15% travel required.Job QualificationsRequired EducationBachelor's or Master's Degree in a social science, psychology, gerontology, public health or social work.Required ExperienceMinimum two years UM, CM, MAT, HM, DM, and/or managed care experience.

Keywords: APN Consulting, Long Beach , Healthcare - Clinical Services Auditor, Other , Long Beach, California

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