Clinical Operations Auditor I/II - 002602
Company: Excellus BlueCross BlueShield
Location: Buffalo
Posted on: January 24, 2023
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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):
Keywords: Excellus BlueCross BlueShield, Buffalo , Clinical Operations Auditor I/II - 002602, Accounting, Auditing , Buffalo, New York
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