Compliance Auditor Clinical

Centene Corporation Woodland Hills , CA 91367

Posted 1 week ago

Position Purpose:

Lead compliance audits of vendors. Identify audit scope and required audit tools. Ensure audit results are appropriated compiled and accounted for within designated audit tools

Manage, audit, and monitor both internal and external vendors against CMS, contractual, Federal, State, and NCQA standards

Review vendors documented processes against contractual, Federal, State, CMS, and NCQA standards

Identify process gaps and deficiencies and communicate audit observations, recommendations, and process improvement opportunities

Develop and implement quality improvement and corrective action plans based on risk analysis, audit findings, and vendor performance

Develop audit tools based on contracted services with vendors and requirements defined by CMS, State, Federal, Medicaid and/or NCQA guidelines

Maintain documentation on vendor performance and provide reports to subsidiaries as required for audits and risk assessments. Lead vendor performance oversight meetings with impacted business owners and vendors

Utilize clinical knowledge to determine audit findings and in answering counterclaims

Train internal audit participants/business owners on audit tools and Medical Management criteria including CM, DM, and UM
80% travel required

Lead, monitor and evaluate the performance of national delegated vendors according to CMS, NCQA, Federal and State requirements.

Education/Experience:

Bachelor's degree in a clinical field or equivalent experience. 4 years of combined clinical and compliance or auditing experience in a healthcare environment. Familiarity with Health Insurance Marketplace, Medicaid and Medicare managed care practices and policies preferred.

Licensure/Certifications:

Current state RN license required. Valid driver's license.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.


icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Lead Delegation Oversight Compliance Auditor (Clinical)

Centene Corporation

Posted 2 months ago

VIEW JOBS 1/25/2019 12:00:00 AM 2019-04-25T00:00 Position Purpose: Serve as liaison between management and auditors. Assist management to ensure contractor's performance is consistent with expectations, policies, procedures and requirements. Assist with training, process improvement and new technology implementation. Lead the coordination of regulatory audits, including reviewing and approving universe submission. Act as resource to the auditors regarding contract and regulatory requirements, as well as the communication of new or revised requirements. Assist with conducting onsite activities in response to whistleblower letters to regulators, self-disclosures of non-compliant activities or regulator notices. Ensure contractor's performance is consistent with expectations, policies, procedures and requirements. Review delegate performance reports and identify significant trends. Report to management on critical cases and issues. Conduct onboarding, training, process improvement and new technology implementation. Coordinate the daily operations of the staff and serve as subject matter experts for ongoing process improvements. Lead detailed workgroups with auditors to review compliance and performance of providers/vendors while executing on delegated UM functions. Education/Experience: Bachelor's degree in Nursing or related field. Master's degree preferred. 4 years of experience in in health care, health plan and/or provider group, auditing and/or investigation, utilization management, concurrent review, case management. License/Certification: Current state's RN license Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Centene Corporation Woodland Hills CA

Compliance Auditor Clinical

Centene Corporation