Clinical Services Auditor

TotalMed Medfi
Remote in Long Beach, CA Full Time
POSTED ON 7/9/2022 CLOSED ON 7/20/2022

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

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