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Sr. Associate, CM Delegation Audit

Job Profile Summary

We are seeking a talented Senior Associate, Care Management Auditing to help manage our care management documentation compliance. You’ll work closely with our care team members, care team leads, Quality team, and Market Operations team. This is an exceptional opportunity for a process-oriented, hungry self-starter who is interested in a cross-functional role at a rapidly scaling organization.

Job Description

Primary Responsibilities

  • Manage multiple audits and related projects, make judgements around objectives and scope, ensure effective and efficient audit execution.
  • Monitor, analyze data reported, and identify non-compliance with regulatory requirements and issue corrective action plans (CAPs) as required.
  • Develop, implement and manage corrective action plans (CAPs)/recommendations when deficiencies are identified and document follow-up to completion.
  • Act as an operational expert and interventionist through communication, education and design of programs and strategies to assist delegated entities to meet regulatory and accrediting standards.
  • Aggregate and analyze audit findings into a reportable format and report to appropriate departments.
  • Evaluate and validate Care Management required reporting to ensure continued compliance with delegated responsibilities.
  • Develop, prepare and analyze performance reports for management review and present to various levels of management and committees.
  • Participate in Care Management/Clinical Committee meetings.
  • Assist with planning and implementation of formal education sessions to Market Ops teams to address non-compliance issues.
  • Collaborate with internal business units to support reporting requests and maintain reports.
  • Works with the Delegation Oversight Manager to develop and maintain delegation audit calendar, tools, policies and reporting templates.
  • Assist with preparation of documents for CMS and/or other regulatory audit audits as needed by our health plan partners.
  • Develop and maintain policies and procedures.
  • Other projects and duties as assigned.

Qualifications

  • Bachelor’s degree in Nursing, or Social Work, or Masters in Healthcare Administration preferred; however, an equivalent combination of education and experience that provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements
  • Minimum 2 year accreditation experience; NCQA, URAC, and/or CMS regulations.
  • Strong knowledge of managed care principles and delivery systems, medical management process, accreditation and regulatory standards delegated oversight processes, and workflow systems.
  • Knowledge of managed care compliance, CMS regulatory and NCQA standards.
  • Strong ability to quickly build relationships and trust with our clinical and clinical ops teams
  • Strong understanding in Medicaid and Medicare requirements across multiple states

How We Define Success: 

  • Self-starter and able to work independently.
  • Knowledge of audit processes and applicable federal regulatory and accredited standards.
  • Must possess a high level of organizational skills to maintain accurate records and documentation.
  • Attention to detail with analytical and problem-solving capabilities.
  • Ability to take initiative and see tasks to completion.
  • Experience with Google suite of products
  • Excellent verbal and written communication skills and able to maintain positive relations with internal and external partners at all levels.
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.

Nice to Have, But Not Required:

  • Prior experience working in a start-up setting
  • Prior experience working with Google products

Working Conditions

  • While performing the duties of this job, the employee works in normal office working conditions.

Disclaimer: The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands, and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.


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Sr. Associate, CM Delegation Audit

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