(Archived) RN, NURSE AUDITOR AND GLOBAL RISKS CONTRACTS COMPLIANCE COORDINATOR

• • Position Overview: 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. Coordinates onsite visit and facilitates meetings and audit process.

Required Qualifications:

• Current, unrestricted NYS RN license required
• 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
• Proficient with Microsoft Office applications including Word, Excel, and PowerPoint
• Willing to occasionally travel as deemed necessary
• 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
• 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

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