This position performs audit functions for the Quality Management team and delegated vendors and partners to determine operational efficiency, adherence to regulatory requirements and achievement of quality standards.
Duties and Responsibilities:
The Quality Clinical Auditor will conduct, review, analyze and summarize findings of audit plans for internal business units and delegated partners and entities on a monthly, quarterly and/or annual basis. Focuses specifically on HEDIS audits and initiatives, supporting documentations and authorization to ensure compliance with regulation, policy and procedures for multiple lines of business. This includes collecting, aggregating, sorting and communicating summary of data collected and utilizing excel pivot tables, charts and graphs to share findings and prepare materials for reporting purposes.
Assist with evaluating and analyzing ad hoc quality performance data to develop strategies for implementing Performance Improvement initiatives. This includes: identifying opportunities for improvement, problem prioritization and creating performance improvement plans for non-compliant audits and/or reports.
Contribute creative solutions and ownership of daily assignments for seamless communication and systematic completion of routine and special projects.
Working under the direction of the Quality Director, maneuvers multiple tasks independently with a fast-paced proactive vs. reactive approach to changing priorities.
Maintain tracking tools that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings.
Assist departments with creating and revising audit tools, as necessary, to ensure audits and reports are value added to the business(s) owner.
Assists in assuring regulatory compliance requiring Clinical RN oversight and review.
Investigates all potential quality of care issues reported in coordination with the Medical Director and Peer Review Committee.
Responsible for maintaining timely reporting for all regulatory reporting, including medical record review and Quality Improvement Plans/Performance Improvement Plans.
Participates in maintaining compliance with URAC and NCQA accreditation standards.
Complete in-office provider audits and education as deemed appropriate pertaining to HEDIS and potential quality issues.
Registered Professional Nurse (RN) License.
Experience in medical records review, claims processing or utilization/case management in a clinical practice or managed care organization. This should include experience analyzing various types of data and processes with ability to present findings and recommendations
Experience in Quality Management initiatives, reporting and HEDIS oversight
NCQA and URAC survey preparation
Experience in Medicare Advantage, Health Exchange and Medicaid lines of business
Availability to travel up to 20% for auditing purposes and member safety oversight
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.
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