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Clinical Auditor 

resume-library  |  United States  |  

United StatesUnited States (US)
Work Type:
Work Time:
Full Time


Clinical Auditor

Job Description: JOB SUMMARY:

The primary role of the Clinical Auditor is to evaluate the operational effectiveness of clinical-decision making, business processes, management, and related internal controls. Additional key functions include: identifying process deficiencies and gaps which directly impact internal departmental efficiencies as well as regulatory and accreditation requirements (CMS, NCQA). This role requires general clinical, system, and business process knowledge related Utilization Management, Case Management, Billing and Coding, and Claims areas. This role is responsible for interacting directly with internal and external Management within the various business areas.

Essential Functions:

The essential functions listed represent the major duties of this role, additional duties may be assigned.

Design and administer audit programs which meets the clients business needs (Utilization Management, Case Management, Disease Management, Payment integrity Office, and other business areas)

Evaluating the Health of the business through assessments over the effectiveness of business processes and controls to include the following:

Identification of risks and control/process gaps through root cause analysis within the current business processes

Oversight of the Clinical Audit process improvement and corrective action plans

Monitoring and identification of trends through data analysis which drive process efficiencies and improve compliance adherence

Collaborate with Medical Directors, Managers, Sr. Managers, Peers, and internal staff

Participate in Improvement Projects

Additional Required Qualifications:

Experience in one or more of the following: home health care, rehab, utilization review, discharge planning or case management

Experience with the health insurance industry (Managed Care)

Experienced in MS Word and Excel

Occasional travel within the State of Florida

Additional Preferred Qualifications:

Experience in Disease Management/Case Management preferred

Experience/knowledgeable of internal documentation applications, i.e. Jiva, Diamond

Experience developing and/or conducting documentation audits for Clinical/Quality *Documentation Audit Program

Bilingual English/Spanish

Required Work Experience:

2+ years related work experience (Clinical experience in a hospital setting)

Required Licenses and Certifications

RN - Registered Nurse - State Licensure And/Or Compact State Licensure (Current Florida RN license)

Comments for Suppliers: Requesting contractor to conduct audits thru 12/31/2022

100% Remote (Must have an active and clear FL RN License)

- Will be auditing other nurses and sometimes MDs aProductst specific Medicare standards. (Will require Medicare/CMS specific experience and understanding).

- Working to ensure care providers are meeting min. Medicare care standards.

- Working Medical Necessity and Appeals.

- Prior Client experience is highly preferred as they will have limited time to get up to speed.