Clinical Auditor

Responsibilities

• As a member of the Corporate Clinical Auditing team, the Clinical Auditor coordinates and completes associate quality audits of clinical staff, focused reviews, and problem identification. Provides coaching and feedback to associates as necessary. Provides routine/scheduled and ad hoc audit reports, including trend identification and root cause analysis. Coordinates development of action plan for identified issues. Participates and assists in the development of necessary protocols, policies and procedures, and operational strategies for Clinical Services. Provides a report tracking compliance with timeliness as mandated by applicable legislative and accrediting organizations, including trend identification and root cause analysis. Coordinates development of action plans for identified issues. Responsible for ongoing development of audit tools to meet business needs. Participates in Quality Reviews and Inter Rater Reliability process as requested. Works with the management team to develop and provide individual and department-level performance improvement plans and activities as well as plan/process follow-up.
• Additionally, the Clinical Auditor will interface with delegated provider groups, complete required auditing and reporting related to provider/subcontractor delegation, and ensure adherence with NCQA , state and business requirements. Serves as a key contact for delegated provider groups, ensures compliance with established contract, and monitors provider/subcontractor performance. Specific responsibilities and tasks may vary based on area within Corporate Quality and Accreditation, Medical Excellence (outlined below).
• In addition to the following responsibilities, the clinical auditor will manage the pre-delegation and annual delegation audit to include auditing for clinical related activities such as utilization management and care management and appeals functions. Assessments will include auditing of clinical activities performed by the delegates. Will ensure compliance with NCQA and State/federal regulations from a clinical perspective.
• Supports Delegation Oversight across the multiple lines of business and business products;
• Supports implementation of new subcontractor and/or new LOB to existing subcontractors by facilitation of meetings, contract requirements analysis and the interface of multiple departments and subcontractors
• Assist with creating supporting clinical auditing tools for internal or external auditing.