Clinical Services Auditor
The Judge Group Inc.

Location: Long Beach, CA
Description:
Judge Healthcare is currently seeking a Clinical Services Auditor to join our client's growing team in the Long Beach, CA area! This position is REMOTE but candidate must live in or near Long Beach.

Schedule: Monday to Friday, 8:30am to 5:30pm PST

This job will have the following responsibilities:

• Performs monthly auditing of registered nurse and other clinical functions in Utilization Management (UM), Case Management (CM), Member Assessment Team (MAT), Health Management (HM), and/or Disease Management (DM) and monitors key clinical staff for compliance with NCQA, CMS, State and Federal requirements. May also perform non-clinical system and process audits, as needed.
• Audits for clinical gaps in care from a medical and/or behavioral perspective to ensure member needs are being met.
• Assesses clinical staff regarding appropriate clinical decision-making. • Reports monthly outcomes, identifies areas of re-training for staff, and communicates findings leadership.
• Ensures auditing approaches follow a Molina standard in approach and tool use.
• Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications.
• Adheres to departmental standards, policies, protocols.
• Maintains detailed records of auditing results.
• Assists HCS training team with developing training materials or job aids as needed to address findings in audit results.
• 15% travel required.
  

Qualifications & Requirements:

• Bachelor's or Master's Degree in a social science, psychology, gerontology, public health or social work.
• Must have an LVN or RN (CA State license)
• Must have at least two years of experience in Utilization Management (UM)
  
• One year of auditing/ clinical review experience preferred
  
• Two years CM, MAT, HM, DM, and/or managed care experience preferred.

If you or someone you know is interested in this position, please send a current resume to Kelly at kjackson@judge.com or 214-281-5947

Contact: kjackson@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

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