Clinical Auditor

Richmond VA 23233

Job Description

Supports goals, contract, and accreditation requirements of health plan in conducting reviews of clinical interactions and clinical documentation including reviews of case management, utilization management, vendor, and provider records. Collects data following established procedures and analyzes findings for purposes of continuous quality improvement and for internal and external reporting. Interacts with multiple stakeholders internally and externally. Conducts staff audits, process audits and pre-delegation and delegation activities. Results of the audits are discussed with appropriate leadership and trainings are developed/edited in conjunction with the training team to identify for individuals and/or for unit learning gaps.
  • Audits and reviews case managers, health guides, utilization management (UM) staff, vendors and provider documentation and telephone interactions against health services quality monitoring standards, regulations, accreditation standards and contract requirements. Reviews vendor and/or provider records against clinical and procedural established standards and contract requirements.
  • Conducts ongoing activities which monitor established quality of care standards in the participating provider network, vendors, UM staff, Health Guides, and for case managers.
  • Collects, analyzes and prepares record/document information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services. 
  • Prepares monthly performance reports with assistance from the Reporting and Analytics Unit.  Presents findings at provider, customer, utilization and care management meetings as needed.
  • Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for vendors, providers, UM staff and case managers.
  • Responsible for monitoring and validating internal audit results and/or corrective action plans.

General Job Information

Title

Clinical Auditor

Grade

23

Job Family

Clinical Services Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

7/2/2019

Date Requisition Created

6/28/2019

Work Experience

Clinical, Quality

Education

Associates: Nursing (Required), Bachelors: Social Work (Required)

License and Certifications - Required

LCSW - Licensed Clinical Social Worker - Care Mgmt, LMHP - Licensed Mental Health Professional - Care Mgmt, LMSW - Licensed Master Social Worker - Care Mgmt, LPC - Licensed Professional Counselor - Care Mgmt, MFT - Marriage and Family Therapist - Care Mgmt, RN - Registered Nurse, State and/or Compact State Licensure - Care Mgmt

License and Certifications - Preferred

Other Job Requirements

Responsibilities

Preferred Qualifications

  • Managed health care utilization management and/or care management experience
  • Experience with NCQA and URAC accreditation standards and processes

Required Qualifications

  • Must be licensed clinician.
  • 5+ years healthcare quality improvement.
  • Experience in working in a quality improvement and healthcare area with demonstrated auditing and clinical expertise in assigned area. 
  • Ability to work independently with minimal supervision. 
  • Project management skills and demonstrated experience a plus.
  • Strong communication skills, attention to detail, organizational skills, with demonstrated competence in writing reports and professional presentations.
  • Skills in word processing, spreadsheets, database management.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.

“I receive a high level of support from our Senior Management Team to execute on our vision. They are always accessible and approachable, something I’ve found to be very unique to Magellan.”