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The Clinical Auditor will conduct routine oversight, monitoring and auditing, of externally delegated functions to ensure compliance with state, federal, and accreditation standards.
- Independently manages multiple concurrent and retrospective audits and monitoring efforts, and related projects; makes judgments around objectives and scope of regulatory adherence and ensures effective and efficient audit execution.
- Researches regulations and informs delegates of any changes to regulatory requirements.
- Conducts mock audits of delegated clinical functions using audit tools and develop corrective action plans to address any identified issues.
- Performs readiness audits for applicable areas to ensure that the entity’s ability to perform activities prior to contract execution.
- Completes annual oversight audits for applicable areas for existing entities to ensure they perform the activities in accordance with the agreement.
- Collects and summarizes performance data and present findings to all applicable committees.
- Participates in workgroups that address both clinical and non-clinical activities for which CalOptima must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS), California Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC), and any other applicable entity.
- Serves as knowledge expert for clinical and quality areas.
- Participates in the Audit & Oversight Committee and ad hoc escalation meetings, when necessary.
- Other projects and duties as assigned.
- Work independently, while having excellent time management and organization skills. Applicant must also be able to prioritize, manage multiple tasks, and have strong attention to detail.
- Organize and administer a complex project plan for the achievement of organizational and audit and oversight goals and objectives.
- Demonstrate and motivate others in effective team coordination and cooperation.
- Establish and maintain effective working relationships with all levels of staff, other programs, agencies and the public.
- Assist in the formulation of policies and procedures; understand and interpret policies, procedures and regulations.
- Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Services.
Experience & Education:
- Bachelor’s degree in Health Sciences, Public Health, Health Administration, Nursing or other related field; or equivalent combination of education and work experience required.
- Minimum current, unrestricted LVN license to practice in the state of California is required, RN preferred.
- Minimum 2 years of experience in utilization management or equivalent experience required.
- At least 1 year of experience in a health care delivery system, including health plan, medical group, or hospital management preferred.
- Valid driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for work away from the primary office 25% of the time or more.
- Legislative, regulatory and utilization management and quality requirements for health care service delivery to beneficiaries of the following programs: Medi-Cal, Cal MediConnect, and Medicare.
- Managed care compliance for Medi-Cal and Medicare.
- Principles and techniques of project management to ensure that numerous goals, objectives and detailed actions are properly identified, and their status monitored.
- Principles and practices of managed health care, health care systems, and medical administration.
- Clinical criterial application/sources and utilization management processing of prior authorization requests, as well as retrospective and concurrent requests.