Performs file audits of the Care Management process to evaluate contractual and regulatory adherence with case and disease management standards and / or utilization management determinations. Participates in development of audit tools, conducts file reviews with objectivity and accuracy, appropriately escalates areas of concern and participates in meeting presentations of audit results. Actively participates in departmental initiatives to ensure audit project time lines and expectations are met.
Department: Health Services
Reports to: Manager, HS, Clinical Quality
Location: Tampa, FL
- Conducts file audits as assigned for Care Management clinical adherence which includes utilization management, case management and disease management.
- Participates in the development and ongoing review of audit tool clinical elements that accurately capture adherence with required standards.
- Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of audit elements, departmental processes, staff training, and contractual/regulatory standards.
- Utilizes clinical knowledge and experience to evaluate documentation of member health assessments, clinical needs and interventions in meeting compliance standards.
- Participates in meetings with Care Management and others to discuss audit findings, areas of opportunity and recommendations for improvement.
- Appropriately escalates areas of concern identified during clinical file audits.
- Participates as needed with preparation for State and Regulatory audits by collecting and /or reviewing evidence.
- Meets established productivity and accuracy standards for file reviews.
- Follows departmental audit guidelines and processes.
- Other duties as assigned.
- Required A High School or GED with directly related equivalent experience
- Preferred An Associate's Degree in Nursing, Clinical Social Work/Counseling
- Required 3 years of experience in clinical compliance auditing, i.e. CMS, AHCA, NCQA, EQRO or managed care environment
- Preferred Other Managed Care experience in UM, BH, CM, or DM
- Preferred Other Familiarity with Medicare and Medicaid programs
Licenses and Certifications:
- Intermediate Ability to effectively present information and respond to questions from peers and management
- Intermediate Demonstrated project management skills
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Ability to work within tight time frames and meet strict deadlines
- Advanced Ability to work as part of a team
- Advanced Demonstrated interpersonal/verbal communication skills
- Intermediate Other Ability to read, analyze and interpret state and federal laws, rules and regulations
- Advanced Other Ability to assess, analyze, make recommendations and report findings verbally and in a formal written summary
- Advanced Other Demonstrated technical expertise in performing quality reviews along with analysis of results.
A license in one of the following is required:
- Required A license in one of the following is required: Other
- Required Licensed Registered Nurse (RN)
- Required Licensed Practical Nurse (LPN)
- Required Licensed Clinical Social Worker (LCSW)
- Required Licensed Mental Health Counselor (LMHC)
- Required Intermediate Microsoft Excel
- Preferred Beginner Microsoft Access
- Required Advanced Microsoft Outlook
- Required Intermediate Microsoft Word
- Preferred Advanced EMMA
- Required Advanced InterQual
- Preferred Intermediate Health care Management Systems (Generic)