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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.
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.
Additional Responsibilities:Candidate Education:
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
Intermediate Ability to effectively present information and respond to questions from peers and management