Senior Digital Auditor
GE HealthCare
Delegation Oversight Auditor I
Gold Coast Health Plan
full-time
Posted on:
Location: California • 🇺🇸 United States
Visit company websiteSalary
💰 $73,500 - $110,250 per year
Job Level
Mid-LevelSenior
About the role
- Lead, coordinate and perform pre-delegation and routine audits for delegates related to clinical program oversight
- Coordinate scheduling of audits, develop audit findings, aggregate and analyze results, and write audit reports including corrective action plans (CAPs)
- Assist in development and implementation of quality improvement, remediation plans and CAPs based on risk analysis and audit findings
- Maintain accurate recordkeeping of all audits and ensure deadlines are met
- Oversee and assist in revision of delegation oversight audit tools per ICE, NCQA, Plan policies, State and Federal guidance
- Provide training, education, and consultation to delegates as necessary
- Collaborate with Delegation Oversight staff and Health Services to develop Joint Operations Meeting (JOM) agendas
- Present at Compliance Committee, Quality Improvement Committee, and create memos, charts and graphs for presentations
- Monitor delegated activities to ensure compliance with NCQA, CMS and State Medicaid requirements and delegation agreements
- Support Audit projects with clinical components and assist with regulatory audit preparation and coordination
- Serve as liaison between subcontracted providers and the Plan; support the compliance department and convey regulatory requirements
Requirements
- High School Graduate or General Education Degree (GED) required
- Bachelor’s Degree (four-year college or technical school) required; fields: BSN, Business, Health Sciences, Managed Care
- Equivalent in lieu of degree: will accept four years of experience in any combination of academic education, professional training, or work experience
- 5+ years of experience in a clinical setting performing Audit, Utilization Review, Delegation Oversight Auditing and UM activities
- 1–2+ years of Audit experience preferred
- 5+ years NCQA, CMS, and/or state Medicaid UM auditing experience
- 3+ years supporting, training, and mentoring others in Managed Care clinical functions (prior authorization, medical record reviews, care management, member grievances, quality reviews)
- Project Management experience preferred
- Advanced proficiency in Microsoft Word, Excel, Access, and PowerPoint
- Preferred certifications: CMAS, CPHM, CPHQ, CPUR, CCM, RN
- Ability to establish and maintain strong working relationships with delegated entities
- Ability to maintain detailed and accurate records, follow directions, prepare agendas, and transcribe minutes
- Ability to work effectively under pressure and handle public contact; strong judgment, communication, presentation, and interpersonal skills
