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Clinical Auditor, Sr.

Company: CalOptima
Location: Orange
Posted on: June 5, 2024

Job Description:



Clinical Auditor, Sr.

CalOptima

CalOptima Health is seeking a highly motivated an experienced Clinical Auditor, Sr. to join our team. The Clinical Auditor Sr will serve as the auditor for clinical and quality areas within the Case Management department. The incumbent will ensure regulatory (Medicare and Medi-Cal including Whole Child) and accreditation National Committee for Quality Assurance (NCQA) compliance for all CalOptima Health lines of business by conducting routine oversight, monitoring and auditing of Case Management department functions to ensure compliance with state, federal and accreditation standards.

Position Information:

  • Department: Case Management
  • Salary Grade: 313 - $90,820 - $145,312 ($43.66 - $69.8615)
  • Work Arrangement: Full Telework

    **This position is eligible for telework in California.**
    Duties & Responsibilities:
    • 85% - Program Support
      • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
      • Conducts ongoing analysis/assessment and auditing of operational performance for continuous process improvements, improved efficiency, and improved customer satisfaction.
      • Manages multiple concurrent and retrospective audits for quality and accuracy by comparing clinical processes against existing standards for the purpose of improving members quality of care, monitors efforts, and related projects; makes recommendations around objectives and scope of regulatory adherence; best practices related to clinical decision making; improving member care and ensures effective and efficient audit execution. Identify patterns of non-compliance, opportunities for improvement and develops corrective action plans to address any identified issues.
      • Creates and updates audit tools to meet all regulatory requirements and the needs of case management processes, along with presenting the audit tools and expectations to all department team members.
      • Audit topics include but are not limited to:
        • Case management functions, assessments, care plans, Interdisciplinary Care Team meeting timelines, and timelines for OneCare, Medi-Cal, and Whole Child Model
        • Transitional Care Services
        • NCQA Accreditation requirements
        • Health Risk Assessment and Health Needs Assessment timelines
        • Mailing timelines
        • Participates in workgroups that address both clinical and non-clinical activities for which CalOptima Health must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS), National Committee for Quality Assurance (NCQA), and any other applicable entity.
        • Establishes and facilitates routine communication and feedback mechanisms of findings to team members and management. Additionally, utilizes findings and trends to improve policies, procedures, and general staff knowledge via training.
        • Serves as subject matter expert (SME) for clinical and quality areas.
        • Serves in a lead capacity over non-senior level staff within the department.

        • 10% - Administrative Support
          • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
          • Researches regulations and tracks changes to regulatory requirements to audit needs.
          • Participates in the Audit & Oversight committee and ad hoc escalation meetings, when necessary.
          • Collects, summarizes, and reports performance and quality data findings to management and all applicable committees.
          • Evaluates various types of information for integrity, accuracy, and appropriateness.

          • 5% - Completes other projects and duties as assigned.
            Minimum Qualifications:
            • For candidates without LVN or RN license, a master's degree in social work, gerontology, public health or related field is required.
            • 5 years of experience in auditing and health plan case management required.
            • An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.


              Preferred Qualifications:
              • Certified Case Manager (CCM) certificate.

                Required Licensure / Certifications:
                • Active Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license to practice in the state of California required.
                  Knowledge & Abilities:

                  • Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
                  • Work independently and exercise sound judgment.
                  • Communicate clearly and concisely, both orally and in writing.
                  • Work a flexible schedule; available to participate in evening and weekend events.
                  • Organize, be analytical, problem-solve and possess project management skills.
                  • Work in a fast-paced environment and in an efficient manner.
                  • Manage multiple projects and identify opportunities for internal and external collaboration.
                  • Motivate and lead multi-program teams and external committees/coalitions.
                  • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
                    Physical Requirements (With or Without Accommodations):
                    • Ability to visually read information from computer screens, forms and other printed materials and information.
                    • Ability to speak (enunciate) clearly in conversation and general communication.
                    • Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
                    • Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
                    • Lifting and moving objects, patients and/or equipment 10 to 25 pounds
                      Work Environment:

                      If located at the 500, 505 Building or a remote work location:
                      • Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
                      • There are no harmful environmental conditions present for this job.
                      • The noise level in this work environment is usually moderate.
                        If located at PACE:
                        • Work is typically indoors in a clinical setting serving the frail and elderly.
                        • There may be harmful or hazardous environmental conditions present for this job.
                        • The noise level in this work environment is usually moderate to loud.
                          If located in the Community:
                          • Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
                          • Employee will occasionally work outdoors in varied temperatures.
                          • There may be harmful or hazardous environmental conditions present for this job.
                          • The noise level in this work environment is usually moderate to loud.
                            About CalOptima Health:
                            CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto "Better. Together. is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!

                            About our Benefits & Wellness options:
                            At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the 2024 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.

                            IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS

                            Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is June 6, 2024 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

                            The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

                            The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.

                            Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.

                            CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

                            CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

                            If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) ###-#### if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.


                            To apply, please visit:







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Keywords: CalOptima, Orange , Clinical Auditor, Sr., Accounting, Auditing , Orange, California

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