General Function: The Nurse Auditor is responsible for maintaining compliance and monitoring and reporting compliance issues for the functions of Complex Case Management, Disease Management , Transitional Case Management and Model of Care. The Nurse Auditor interfaces with health plans, and has oversight of health plan delegated reports. Monitoring includes review of the work of others that perform service delivery of delegated member programs and providing feedback to ensure that delegation requirements pertaining to NCQA and CMS are met. Health plan and delegate interface requires participation in external audits of CM, DM, and MOC programs, monitoring policies and procedures, and preparation and review of clinical files. Delegated reporting functions include report preparation, validation, and submission of CMS quality reports as well as health plan reports on programs and metrics according to delegation agreement. This position requires a subject matter expert who is able to provide innovative solutions to complex problems and lead quality improvement initiatives for remediation.

Job Components:

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

• Read and interpret standards/ requirements/ technical specifications such as NCQA, MOC, CMS
• Evaluate current processes, compare to relevant standards or specifications, and identify gaps in compliance or performance
• Work cross-functionally, making recommendations or clarifying information to assist in closing gaps
• Develop crosswalk documents for changes to regulatory requirements and disseminate
• Establish and execute a comprehensive internal audit process for all delegated contracts
• Independently conduct clinical audits and record reviews for all delegated lives to assess process accuracy and completion
• Develop detailed and actionable findings reports based on findings from audits
• Ensure compliance with contractual requirements related to audits

• Document work performed and contribute to work instructions for the team to ensure process calibration
• Training new hires regarding health plans' documentation requirements
• Training and re-training of staff who achieve less than 95% compliance for all clinical documentation requirements

• Report audit findings and recommended remediation to management team

• Assume responsibility for inter-rater reliability of clinical audit activities

• Analyze data, identify trends, and develop reporting capabilities for the work performed
• Create or contribute to presentations that relay audit findings and trends
• Provide analytical support and expertise when compiling report information

• Interfaces with health plans and acts as liaison for delegated services
• Reviews delegation agreements and has a clear understanding of delegated services and reporting requirements
• Anticipates plan requirements and proactively works on solutions to meet requirements
• Serves as a resource for complex issues and performs analysis and provides solutions for resolution
• Has authority to approve deviations from standard procedures related to complex issues
• Serves as the primary contact and delegation resource for health plans
• Informs and educates health plan personnel regarding regulatory and accreditation standards
• Manages the external audit process end to end to include routine delegation as well as new payor pre-delegation
• Plans in advance for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirements

• Extract appropriate data for Health Plan audits and internal performance monitoring
• Develop and implement effective analysis, research and evaluation in preparation for clinical monitoring audits activities

• Coordinates onsite visit and facilitates meetings and audit process
• Prepares and submits document requests and support the development of case universes
• Prepares and audits file requests based on regulatory and accreditation requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before the audit
• Coaches and mentors care management staff involved in audit etiquette and regulatory standards
• Participates in delegation audits and assists UM, CM, DM departments with supplying information as needed

• Present case files during external audits (Health Plan, CMS)

• Guides and influences the audit process by ensuring that auditors adhere to the scope of the audit
• Follows up on action items and attempts to supply all needed information during the audit
• Follows up on corrective action plans ensuring timely closure
• Prepares summary of audit activities and outcomes
• Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur
• Provides direction and expertise on regulatory and accreditation standards to health plan personnel as well as internal personnel

• Coordinate and ensure timely submission all required documents to external organizations (Health Plans, CMS) in response to audits and ad hoc documentation requests

• Provides all required CM and DSNP delegation reports to health plan
• Prepares reports including those that require manual entry
• Validates accuracy of reports prior to submission
• Submits reports timely according to health plan requirements
• Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reports
• Identifies gaps in audit findings versus internal performance findings
• Fosters open communication with managers/directors by acting as a liaison between national Optum teams and Optum Care team
• Identify and communicate with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies
• Identify and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership
• Collect audit result data and prepare comparison reports to internal performance standards and identify risk
• Collect additional data as needed to assist in gap closure
• Analyze results, provide interpretation, and identify areas for improvement
• Develop and utilize effective methods for data collection and quality improvement
• Provide training to managers, medical directors, and staff on regulatory information by developing educational materials, providing educational in-services, and/ or on a one-to-one basis
• Oversee annual delegated program evaluations, program descriptions, policies & procedures
• Lead teams to update program descriptions

• Assists in policy reviews and updates

• Lead teams to collect data and analyze necessary and relevant to program evaluations
• Involve key stakeholders in requests for policy change
• Monitor care management policies for updates, approvals and ensuring annual evaluation
• Responsible for providing all internal and external results compared with goals for annual program evaluations and presentation to the Medical Management Committee

• Collaborate with departmental leadership to achieve NCQA designation for Case Management
• Participate in departmental meetings and activities

• Interacts with the health plans in scheduled meetings and actively participate in Joint Operations Committees reporting issues and pro-actively solving problems
• Identifies opportunities for process improvement in all aspects of member care
• Must maintain strict confidentiality at all times
• Must adhere to all department/organizational policies and procedures
• Performs all other related duties as assigned

Required Qualifications:

To perform this job successfully, an individual must have the following education and/or experience.

• Current, unrestricted RN license required, specific to the state of employment

• Bachelor of Science in Nursing
• 3+ years of diverse clinical experience; preferred in managed care (delegated medical management), Complex Case Management, Disease Management and Transitional Case Management

• Expert knowledge of case management principles, as evidenced by certification in Case Management (CCM) or willing to obtain within 6 months of employment
• Knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, SNP, Commercial) and regulatory bodies (e.g., CMS, NCQA, URAC, InterQual)
• Health Plan or Management Services Organization quality, audit, or compliance experience

• Ability to read, analyze and interpret information in medical records, and health plan documents
• Able to prioritize, plan, and handle multiple tasks/demands simultaneously

• Proficient with Microsoft Office applications including Word, Excel, and PowerPoint
• Willing to occasionally travel as deemed necessary

Preferred Qualifications:

• 5+ years of managed care (delegated medical management), Complex Case Management, Disease Management and Transitional Case Management experience
• Knowledge of utilization management, quality improvement, and discharge planning
• Ability to cultivate a strong internal culture designed around collaboration, feedback, motivation, and accountability
• Solid communication and interpersonal skills
• Demonstrated ability to work in a fast pace, multi-tasking team environment while meeting deadlines
• Highly skilled in leading change efforts and in building strong partnerships with business-line executives
• Ability to summarize complex issues and problems into a concise report focused on key findings and outcomes
• Ability to complete initiatives with minimal supervision
• Proficiency in developing communication strategies for a wide array of audiences that support strategic objectives
• Demonstrated sophisticated written and verbal presentation abilities; experience with the development of presentation materials (collateral, proposals, presentations, talking points, etc.)
• Proven proficiency in the management of time, flexibility, and influencing colleagues to meet demanding project/requested timelines

* Read and interpret standards/ requirements/ technical specifications such as NCQA, MOC, CMS

o Evaluate current processes, compare to relevant standards or specifications, and identify gaps in compliance or performance

o Work cross-functionally, making recommendations or clarifying information to assist in closing gaps

o Develop crosswalk documents for changes to regulatory requirements and disseminate

* Establish and execute a comprehensive internal audit process for all delegated contracts

o Independently conduct clinical audits and record reviews for all delegated lives to assess process accuracy and completion

o Develop detailed and actionable findings reports based on findings from audits

o Ensure compliance with contractual requirements related to audits

o Document work performed and contribute to work instructions for the team to ensure process calibration

o Training new hires regarding health plans' documentation requirements

o Training and re-training of staff who achieve less than 95% compliance for all clinical documentation requirements

o Report audit findings and recommended remediation to management team

o Assume responsibility for inter-rater reliability of clinical audit activities

* Analyze data, identify trends, and develop reporting capabilities for the work performed

o Create or contribute to presentations that relay audit findings and trends

o Provide analytical support and expertise when compiling report information

* Interfaces with health plans and acts as liaison for delegated services

o Reviews delegation agreements and has a clear understanding of delegated services and reporting requirements

o Anticipates plan requirements and proactively works on solutions to meet requirements

o Serves as a resource for complex issues and performs analysis and provides solutions for resolution

o Has authority to approve deviations from standard procedures related to complex issues

o Serves as the primary contact and delegation resource for health plans

o Informs and educates health plan personnel regarding regulatory and accreditation standards

* Manages the external audit process end to end to include routine delegation as well as new payor pre-delegation

o Plans in advance for external audits by forecasting resource requirements and planning to ensure availability of key stakeholders and other resource requirements

o Extract appropriate data for Health Plan audits and internal performance monitoring

o Develop and implement effective analysis, research and evaluation in preparation for clinical monitoring audits activities

o Coordinates onsite visit and facilitates meetings and audit process

o Prepares and submits document requests and support the development of case universes

o Prepares and audits file requests based on regulatory and accreditation requirements in a timely manner to provide key stakeholders an opportunity to correct deficiencies before the audit

o Coaches and mentors care management staff involved in audit etiquette and regulatory standards

o Participates in delegation audits and assists UM, CM, DM departments with supplying information as needed

o Present case files during external audits (Health Plan, CMS)

o Guides and influences the audit process by ensuring that auditors adhere to the scope of the audit

o Follows up on action items and attempts to supply all needed information during the audit

o Follows up on corrective action plans ensuring timely closure

o Prepares summary of audit activities and outcomes

o Monitors data collection tools and ensures updates occur as regulatory and accreditation changes occur

o Provides direction and expertise on regulatory and accreditation standards to health plan personnel as well as internal personnel

* Coordinate and ensure timely submission all required documents to external organizations (Health Plans, CMS) in response to audits and ad hoc documentation requests

o Provides all required CM and DSNP delegation reports to health plan

o Prepares reports including those that require manual entry

o Validates accuracy of reports prior to submission

o Submits reports timely according to health plan requirements

o Interfaces with IT and Care Management and provides direction regarding additional reports or changes to delegation reports

* Identifies gaps in audit findings versus internal performance findings

o Fosters open communication with managers/directors by acting as a liaison between national Optum teams and Optum Care team

o Identify and communicate with appropriate departments, teams, and key leadership on internal audit results and/or deficiencies

o Identify and communicate gaps between CMS and NCQA requirements and internal documentation audits to appropriate departments, teams, and key leadership

o Collect audit result data and prepare comparison reports to internal performance standards and identify risk

o Collect additional data as needed to assist in gap closure

o Analyze results, provide interpretation, and identify areas for improvement

o Develop and utilize effective methods for data collection and quality improvement

o Provide training to managers, medical directors, and staff on regulatory information by developing educational materials, providing educational in-services, and/ or on a one-to-one basis

* Oversee annual delegated program evaluations, program descriptions, policies & procedures

o Lead teams to update program descriptions

o Assists in policy reviews and updates

o Lead teams to collect data and analyze necessary and relevant to program evaluations

o Involve key stakeholders in requests for policy change

o Monitor care management policies for updates, approvals and ensuring annual evaluation

o Responsible for providing all internal and external results compared with goals for annual program evaluations and presentation to the Medical Management Committee

* Collaborate with departmental leadership to achieve NCQA designation for Case Management

* Participate in departmental meetings and activities

* Interacts with the health plans in scheduled meetings and actively participate in Joint Operations Committees reporting issues and pro-actively solving problems

* Identifies opportunities for process improvement in all aspects of member care

* Must maintain strict confidentiality at all times

* Must adhere to all department/organizational policies and procedures

* Performs all other related duties as assigned

Required Qualifications:

To perform this job successfully, an individual must have the following education and/or experience.

* Current, unrestricted RN license required, specific to the state of employment

* Bachelor of Science in Nursing

* 3+ years of diverse clinical experience; preferred in managed care (delegated medical management), Complex Case Management, Disease Management and Transitional Case Management

* Expert knowledge of case management principles, as evidenced by certification in Case Management (CCM) or willing to obtain within 6 months of employment

* Knowledge of relevant state and federal guidelines (e.g., Medicare, Medicaid, SNP, Commercial) and regulatory bodies (e.g., CMS, NCQA, URAC, InterQual)

* Health Plan or Management Services Organization quality, audit, or compliance experience

* Ability to read, analyze and interpret information in medical records, and health plan documents

* Able to prioritize, plan, and handle multiple tasks/demands simultaneously

* Proficient with Microsoft Office applications including Word, Excel, and PowerPoint

* Willing to occasionally travel as deemed necessary

Preferred Qualifications:

* 5+ years of managed care (delegated medical management), Complex Case Management, Disease Management and Transitional Case Management experience

* Knowledge of utilization management, quality improvement, and discharge planning

* Ability to cultivate a strong internal culture designed around collaboration, feedback, motivation, and accountability

* Solid communication and interpersonal skills

* Demonstrated ability to work in a fast pace, multi-tasking team environment while meeting deadlines

* Highly skilled in leading change efforts and in building strong partnerships with business-line executives

* Ability to summarize complex issues and problems into a concise report focused on key findings and outcomes

* Ability to complete initiatives with minimal supervision

* Proficiency in developing communication strategies for a wide array of audiences that support strategic objectives

* Demonstrated sophisticated written and verbal presentation abilities; experience with the development of presentation materials (collateral, proposals, presentations, talking points, etc.)

* Proven proficiency in the management of time, flexibility, and influencing colleagues to meet demanding project/requested timelines

Physical & Mental Requirements:

* Ability to lift up to 25 pounds

* Ability to sit for extended periods of time

* Ability to stand for extended periods of time

* Ability to use fine motor skills to operate office equipment and/or machinery

* Ability to receive and comprehend instructions verbally and/or in writing

* Ability to use logical reasoning for simple and complex problem solving

Full COVID-19 vaccination is an essential requirement of this role. CareMount will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance.

All qualified applicants will receive consideration for employment without regard to race, ethnicity, color, religion, sex, gender identity, sexual orientation, national origin, disability, or protected veteran status. CareMount is an EO employer - M/F/Veteran/Disability

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