Clinical Auditor II
Bcidaho

Job Info

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Our Clinical Auditor will validate and interpret medical records to ensure and capture all relevant coding and billing practices are accurate and appropriate. This individual will identify the root cause analysis of audit findings and submits recommendations for appropriate change management and policy update. The Nurse Auditor will work varied assignments that frequently require interpretation and independent determination to make appropriate audit determinations.

This position can be remote within a mutually acceptable location.

We're looking for a Clinical Auditor with:

Level I:

Experience: 3 years' clinical experience in a health plan and/or health care setting
Education: Associates Degree in Nursing or Bachelor's Degree in Social Work; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)

Licenses/Certifications: Must hold one of the following:

• Valid unrestricted Idaho Registered Nursing License
• Valid unrestricted Idaho Social Worker License

Level II:

Experience: 5 years' clinical experience in a health plan and/or health care setting

Education: Associates Degree in Nursing or Bachelor's Degree in Social Work; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)

Licenses/Certifications: Must hold one of the following:

• Valid unrestricted Idaho Registered Nursing License
• Valid unrestricted Idaho Social Worker License

What a day would look like:

• Performs on-going compliance audits using standard evaluation tools relating to audit/monitoring activities and ensures adherence to regulatory requirements.
• Identifies and defines audit scope and criteria, reviews, and analyzes evidence, and documents audit findings. Makes recommendations for improvement and correction where identified.
• Provides comprehensive advice to assigned department regarding compliance risks with respect to contract provisions, Federal and State regulations.
• Provides input during the annual risk assessment and audit planning processes.
• Performs root cause analysis when compliance, accreditation or clinical gaps are identified and provides results to leadership.
• Assists with monitoring activities involving the effective execution of corrective action requirements imposed by State or Federal regulator agencies for contract deficiencies.
• Ensures effective workflows, maximizes system efficiencies, and monitors quality performance measures; makes recommendations for change as appropriate.
• Provides recommendations for performance improvement and develops a correction action plan when necessary.
• Participates in the development and implementation of performance improvement projects for all product lines.
• Performs other duties and responsibilities as assigned.

Pay Grade 21/23

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

This job has expired.