What are the responsibilities and job description for the Clinical Services Auditor position at TotalMed Medfi?
Location: REMOTE (must be local to Long Beach, CA; there will be an onsite requirement for candidates to report a few times a month to the Long Beach office)
Schedule: Mon-Fri 8:30am-5:30pm PST
Job Description/Requirements:
This person will be conducting/monitoring audit activity to review Utilization Management (UM) decisions.
- 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.
- Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.
- Communicates with QA supervisor/manager about issues identified and works collaboratively to resolve/correct them.
- 15% travel required.
Experience/Education:
- Requires LVN or RN (CA State license)
- Bachelor's or Master's Degree in a social science, psychology, gerontology, public health or social work
- Requires 2 years UM, CM, MAT, HM, DM, and/or managed care experience
- Must have at least two years of experience in Utilization Management (UM)
- Requires 1 year of auditing/ clinical review experience
#INDAS
Job Type: Full-time
Pay: $36.00 - $38.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Vision insurance
Schedule:
- Monday to Friday
Education:
- Bachelor's (Required)
Experience:
- CM, MAT, HM, DM, and/or managed care: 2 years (Required)
- Utilization Management (UM): 2 years (Required)
- auditing/ clinical review: 1 year (Required)
License/Certification:
- LVN or RN (CA State license) (Required)
Work Location: Remote
Salary : $36 - $38