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(Archived) Clinical Auditor- Grievance and Appeals (GARS)
Job Description
Clinical Auditor- Grievance and Appeals (GARS)
Job Description
Department(s): Grievance & Appeals
Reports to: Manager, Clinical Operations - GARS
FLSA status: Non-Exempt
Salary Grade: L - $$77,000 - $109,000
Job Summary
The Grievance and Appeals (GARS) Auditor is responsible for auditing grievance and appeal activity performed within the GARS and delegated Health Networks to ensure that regulatory and internal guidelines are being followed in conjunction with CalOptima policies and procedures. This position has analytical and administrative responsibilities specific to the GARS department.
The incumbent is responsible for auditing CalOptima's Medi-Cal and Medicare programs and requires specialized background and experience regarding grievances, appeals, authorization rules, and regulatory guidelines relevant to grievance and appeals.
Position Responsibilities:
• Independently manages multiple concurrent and retrospective audits and monitors efforts.
• Makes recommendations for objectives and scope of regulatory adherence and ensures effective and efficient audit execution.
• Researches regulations and informs GARS management of any changes to regulatory requirements that impact the auditing protocols.
• Conducts monthly audits of the internal clinical team and delegated Health Networks using audit tools and develops corrective action plans to address any identified issues.
• Collects and summarizes performance data and presents findings to all applicable committees and ad hoc escalation meetings when necessary.
• Participates in workgroups that address both clinical and non-clinical activities for which CalOptima must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS), California Managed Risk Medical Insurance Board (MRMIB), Department of Managed Health Care (DMHC), and any other applicable entity.
• Serves as Subject Matter Expert (SME) for clinical quality areas.
• Develops clinical training materials such as desktop procedures, reference guides, and workflows to improve the efficiency and accuracy of clinical reviews.
• Participates in regulatory or National Committee Quality Assurance (NCQA) audits as needed.
• Other projects and duties as assigned.
Possesses the Ability To:
• Work independently while having excellent time management and organization skills.
• Prioritize, manage multiple tasks, and have strong attention to detail.
• Organize and administer complex project plans to achieve organizational and departmental goals and objectives.
• Demonstrate and motivate others in effective team coordination and cooperation.
• Establish and maintain effective working relationships with staff at all levels, other programs, agencies, and the public.
• Formulate, understand, and interpret policies, procedures, and regulations.
• Communicate clearly and concisely, both verbally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education:
• Bachelor's degree in Health Sciences, Public Health, Health Administration, Nursing, or other related field and/or equivalent combination of education and work experience required.
• Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required.
• 2 years of experience as a Grievance and Appeals Nurse Specialist.
• 2 years of experience in a health care delivery system, including health plan, medical group, or hospital management required.
Preferred Qualifications:
• Current, unrestricted Registered Nurse (RN) license to practice in the State of California preferred.
• 2 years of experience in delegate/internal auditing and utilization management preferred.
Knowledge of:
• Legislative, regulatory, utilization management, and quality requirements for health care service delivery to beneficiaries of the following programs: Medi-Cal, Cal MediConnect, and Medicare.
• Managed care compliance for Medi-Cal and Medicare.
• Project management to ensure that numerous goals, objectives, and detailed actions are properly identified, and their status monitored.
• Managed health care, health care systems, and medical administration.
• Clinical criterial application/sources and utilization management processing of prior authorization requests, as well as retrospective and concurrent requests.
CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.
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Job Location: Orange, California
Position Type:
To apply, visit https://apptrkr.com/2392570
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