Nurse Clinical Auditor

Location: Orange, CA
Date Posted: 08-01-2018
Clinical Auditor  (RN or LVN) – Managed Care
Orange, CA
*** This is a Full Time, Benefits Available, CONTRACT opportunity expected to last 4-5 months, or longer! ***
Clinical Auditor Job Summary:
  • Manage multiple concurrent audits- plan audits and related projects, make judgments around objectives and scope, and ensure effective and efficient audit execution.
  • Research regulations and inform various departments within the health plan and delegates of any changes to regulatory requirements.
  • Conduct mock audits of department functions using audit tools and develop corrective action plans to address any identified issues.
  • Conduct pre-delegation audits for applicable areas to ensure that vendor is able to perform the delegated activities prior to delegation.
  • Conduct annual delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the agreement.
  • Collect and summarize performance data, and present findings to all applicable committees.
  • Participate in workgroups that address both clinical and non-clinical internal activities for which the health plan must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), California Department of Health Services (DHS), California Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC), and any other applicable entity.
  • Serve as knowledge expert for clinical and quality areas.           
  • Participate in the Delegation Oversight Committee meetings.
Clinical Auditor Background:
  • Current unrestricted state license as Registered Nurse (R.N.) or Licensed Vocational Nurse (L.V.N.)
  • Bachelor’s degree in Health Services, Public Health, Business (with quantitative emphasis), Nursing or other related field; or equivalent work experience required.
  • 2+ years of experience in resource/quality management or equivalent experience required.
  • 1+ years of experience in a health care delivery system, including health plan, medical group, or hospital management preferred.
  • Valid driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for work away from the primary office 35% of the time or more.

Erik Berg
443.470.8240 (CALL – TEXT – FAX)
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