Manager Clinical Auditing

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Job Overview

Under the direction of the Director, Corporate Clinical System Administration, Training, and Auditing, the Manager of Clinical Auditing is responsible for day to day operations of the clinical audit team. In this role, you will have oversight of a team of clinical auditors responsible for monthly audits of associates in utilization management, appeals, case management, rapid response, and appeals as well as the audits of external vendors. The Manager of Clinical Auditing focuses on audit consistency, corrective action planning, and executive level reporting, while partnering with all levels of leadership, Medical Directors, and training teams to drive quality improvement.

Work Arrangement

• Remote role
• Monday through Friday, 8:30 AM EST to 5:00 PM EST

Responsibilities

• Oversee the quarterly clinical auditing process, inclusive of associate quality audits, focused audits, ad hoc audits and comprehensive timely reporting of the results
• Participates and assists in the development of protocols, policies and procedures
• On-boards new business/teams to clinical auditing process
• Coordinates the development of action plans for identified issues
• Ongoing management and maintenance of the audit database and audit tools
• Conducts quality reviews and inter-rater reliability (IRR) testing of clinical auditors
• Works with management teams to develop individual and department level performance improvement plans and activities as needed

Education and Experience

• Associate's Degree in Nursing. Bachelor's Degree preferred
• Minimum of 3 years of diverse independent clinical practice experience
• Minimum of 3 years of utilization management and/or case management experience in a managed care organization
• Experience applying NCQA regulatory standards to ensure 100% compliance with clinical file review standards
• Experience executing oversight audits to verify subcontractor compliance with NCQA standards, identifying documentation gaps and implementing Corrective Action Plans (CAPAs) in collaboration with compliance and legal teams
• Experience applying standardized clinical criteria such as InterQual (preferred) to evaluate medical necessity and appropriate level of care
• Experience leading a remote team of licensed clinical professionals
• Experience presenting to external agencies and/or leadership teams the EQRO (External Quality Review Organization) process and clinical auditing team operational processes

Licensure

• Active and unencumbered Registered Nurse license in all states of licensure

Skills and Abilities

• Strong working knowledge of clinical criteria, InterQual preferred
• Demonstrated working knowledge of plan benefit information and managed care, specifically Medicare and Medicaid
• Ability to design and deliver presentations to internal and external stakeholders with confidence and clarity
• Demonstrated ability to design, implement, and manage organizational processes that optimize efficiency and ensure accuracy without relying on automated tools
• Proactive problem-solver with demonstrated ability to manage and resolve high priority escalations
• Proficiency using Healthcare Management Platforms and all components of MS Office with speed and accuracy

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.