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Clinical Operations Auditor I/II - 002602

Company: Excellus BlueCross BlueShield
Location: Buffalo
Posted on: January 24, 2023

Job Description:

Clinical Operations Auditor I/II - 002602 The Auditor is responsible for monitoring the utilization of medical and health care services for members, monitoring care coordination activity and quality of care delivered from Case Management and ensuring compliance with internal and external standards set by regulatory and accrediting entities. This position may also assist with the performance of external and intra-plan audits. Essential Responsibilities/Accountabilities:Level I: - Performs audits in accordance with regulatory requirements of DOH, CMS, DFS, OMH, OASAS and OCFS and NCQA, corporate policies and accreditation requirements such as NCQA functionalities of Utilization Management and Case Management. - Facilitates the setup of audits on a regular cadence and coordinates with the Accreditation and Compliance Quality Administrator to ensure accuracy of audit criteria. - Provides group and individual coaching based on identified audit errors and trends with the intent of improving future performance. Identifies individuals with reoccurring audit errors, escalating to management appropriately. - Communicates quality and accuracy of timeliness against standards set by regulatory and accrediting entities. Adheres to and meets established deadlines as required by management. - Knowledgeable in internal and external regulatory and accrediting entity standards. Assists with the performance of external audits with direction from Management. - Remains current with relevant legislative and regulatory mandates to ensure activities follow these requirements. Also, be aware of all local, regulatory, operational, and national policy changes. - Proposes recommendations for system enhancements, workflow modifications, processing guidelines, system documentation and/or training documentation. - Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs. - Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. - Regular and reliable attendance is expected and required. - Performs other functions as assigned by management. Level II (in addition to Level I essential responsibilities/accountabilities): - Manages more complex assignments; cross-trained to audit various LOB, levels of care and/or services. - Identifies, recommends and assesses new processes as necessary to improve productivity and gain efficiencies for performance improvement opportunities for the department. - Expert and resource for escalations - Serves as subject matter expert and if called upon, works directly with the operation and clinical staff to resolve issues and escalated problems. - Displays leadership and serves as a positive role model to others in the department. Mentor (to others in department) - Provides guidance and leadership to the daily activities of the clinical staff and acts as resource to staff and other departments. - Develop and share best practices through the tracking and trend work. Participate in committees and lead when required. - Assists in updating departmental policies, procedures, and desk level procedures relative to the functions. Lead the training of new staff for documentation of clinical standards. Minimum Qualifications:NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels: - Clinical licensure is preferred. - Minimum of two years of Managed Care Experience. - Two years of clinical experience is preferred. - Utilization Management and/or Case Management experience preferred. - Must demonstrate proficient experience in use of a computer. Example-creating documents, Word, Excel, Internet, and email. - Possess effective verbal and written communication skills. - Demonstrated good interpersonal relations skills. - Ability to successfully manage multiple priorities. Level II (in addition to Level I minimum qualifications):

  • NYS Clinical Licensure required.
  • Must have been in a current utilization management and/or case management position, or similar subject matter expert for at least six years.
  • Must demonstrate proficiency with all aspects of the auditor's role.
  • Demonstrated presentation skills.
  • Broad understanding of multiple areas (i.e. UM and CM). At this level, incumbent is required to know multiple functional areas and supporting systems.
  • Ability to take on broader responsibilities
  • Ability to coach and mentor staff as needed. -Physical Requirements:
    • Ability to work prolonged periods sitting at a workstation and working on a computer.
    • Ability to work in a home office for continuous periods of time for business continuity.
    • Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
    • The ability to hear, understand and speak clearly while using a phone, with or without a headset. ************The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce. -OUR COMPANY CULTURE: Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits. In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.Equal Opportunity EmployerQualificationsEducationRequiredAssociates or better in Review Required.Licenses & CertificationsPreferredMental Health CounselorPhysical TherapistRegistered NurseEqual Opportunity Employer/Protected Veterans/Individuals with DisabilitiesThe contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Keywords: Excellus BlueCross BlueShield, Buffalo , Clinical Operations Auditor I/II - 002602, Accounting, Auditing , Buffalo, New York

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