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.
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.
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.