- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
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CQM Clinical Auditor
1 week ago
Regal Medical Group Los Angeles, United StatesJob Description · Job DescriptionEducation and / or Experience: · Graduate from an accredited school for Nursing (LVN or RN). · Case management experience needed · Current and maintains California Nursing License. · Three to five (3-5) years of clinical experience preferred. · Tw ...
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CQM Clinical Auditor
1 week ago
Regal Medical Group Los Angeles, United StatesJob Description · Job DescriptionEducation and / or Experience: · Graduate from an accredited school for Nursing (LVN or RN). · Current and maintains California Nursing License. · Three to five (3-5) years of clinical experience preferred. · Two to three (2-3) years of managed ca ...
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Um Auditor Clinical Services
1 week ago
Molina Healthcare Long Beach, United StatesMolina Healthcare Services (HCS) works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum, including behavioral health and long term care, for members with high need potential. ...
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University of Southern California Los Angeles, United States Full timeThe Senior Clinical Documentation Specialist - Auditor (CDS) performs review of inpatient medical records to identify documentation opportunities to accurately represent the severity of illness, risk of mortality, length of stay, intensity of service and hospital quality metrics. ...
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Delegation Oversight Clinical Auditor RN II
1 week ago
L.A. Care Health Plan Los Angeles, United StatesSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) · Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation's largest publicly operat ...
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Auditor, Clinical Documentation
1 week ago
Pomona Valley Hospital Pomona, United StatesPosition summary:#The Clinical Documentation and Coding Integrity Quality Auditor performs clinical documentation validation reviews.Performs quantitative and qualitative reviews and analysis of the clinical health records and physician queries both concurrently and retrospective ...
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CQM Clinical Auditor
1 week ago
Regal Medical Group, Inc. Northridge, United StatesJob Description · Position Summery: · CQM auditor performs Quality Monitoring to assure the regulatory compliance and quality of process in daily Utilization Management (UM) activities with minimal to moderate supervision. The auditor will work closely with the business units, Da ...
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Manager, Clinical Quality Assurance Auditor
2 weeks ago
Arrowhead Pharmaceuticals, Inc. Pasadena, United StatesThe Position · This position will lead and participate in Good Clinical Practice, Good Laboratory Practice, Good Pharmacovigilance (GCP/GLP/GVP) audits for clinical research involving pharmaceutical products, including compliance oversight and coordination of the Vendor Qualifica ...
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Manager, Clinical Quality Assurance Auditor
3 weeks ago
Arrowhead Pharmaceuticals, Inc. Pasadena, United StatesJob Description · Job Description · Arrowhead Pharmaceuticals, Inc. (Nasdaq: ARWR) is a clinical stage biopharmaceutical company that develops medicines that treat intractable diseases by silencing the genes that cause them. Using a broad portfolio of RNA chemistries and effici ...
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Manager, Clinical Quality Assurance Auditor
1 week ago
Arrowhead Pharmaceuticals Pasadena, United StatesJob Description · Job DescriptionArrowhead Pharmaceuticals, Inc. (Nasdaq: ARWR) is a clinical stage biopharmaceutical company that develops medicines that treat intractable diseases by silencing the genes that cause them. Using a broad portfolio of RNA chemistries and efficient m ...
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Research Coordinator I
1 week ago
USC Los Angeles, United StatesThis position requires someone with a strong medical background and an interest in clinical research. The role of the Research Coordinator I is a diverse one and will include Data Management responsibilities. This person works independently, yet is able to relate well with physic ...
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Claims Admin Analyst
4 days ago
Kaiser Permanente Los Angeles, United States**Job Summary**: · The purpose of this position is to provide support to the Outside Medical Services department, Responsible for Coordinating and Processing Referrals in accordance with regulatory and organizational referral processing guidelines.Under direct supervision, Respon ...
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Clinic Quality Manager Auditor 3
3 weeks ago
Fresenius Medical Care North America Irwindale, United States**PURPOSE AND SCOPE:** · Develops, implements, maintains and evaluates an effective, data-driven, quality assessment and performance improvement program(s) with participation by other members of the interdisciplinary team. Serves as a quality improvement champion and role model b ...
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Substance Use Disorder Compliance Analyst
2 weeks ago
AMERICAN HEALTH SERVICES Santa Clarita, United States**TITLE: Compliance Analyst** · **LOCATION**:Corporate Office Summit Circle, CA 91350** · Stationed in Los Angeles County - Occasional travel to San Diego, Bakersfield, and San Francisco Areas · REPORTS TO: Director of SUD Operations · TIME/STATUS: Regular, Full-time · **AMERICAN ...
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Molina Healthcare Long Beach, United StatesJob Summary · Molina's Quality Improvement function oversees, plans, and implements new and existing healthcare quality improvement initiatives and education programs; ensures maintenance of programs for members in accordance with prescribed quality standards; conducts data colle ...
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Clinical Research Coordinator I
1 week ago
CEDARS-SINAI Los Angeles, United StatesJob Description · Grow your career at Cedars-Sinai · Cedars-Sinai offers a culture of happiness, passion, and dedication. This is one of the many reasons why we rank as one of the top hospitals in California and in the nation by U.S. News & World Report. · Do you have a passion f ...
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HCC Auditor
2 weeks ago
Century Group Los Angeles, United StatesCentury Group is partnering with a client who is seeking a HCC Auditor to join their team. The HCC Risk Adjustment/Auditor will be responsible for maintaining and monitoring the Quality Assurance auditing plan for outpatient clinical data. Exact compensation may vary based on ski ...
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Claims Quality Auditor
3 weeks ago
University of California Los Angeles, United StatesTake on an important role within a world-class health organization. Provide specialized expertise that enables the efficient operation of a complex health system. Take your career to the next level. You can do all this and more at UCLA Health. · The Claims Quality Auditor will be ...
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Sr. Revenue Cycle Compliance Auditor
1 week ago
Adventist Health NW Los Angeles, United StatesLocated in the metropolitan area of Sacramento, the Adventist Health corporate headquarters have been based in Roseville, California, for more than 40 years. In 2019, we unveiled our WELL-certified campus - a rejuvenating place for associates systemwide to collaborate, innovate a ...
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Risk Coordinator
3 weeks ago
Serve the People Community Health Center Santa Ana, United StatesJob Summary: · Under the general direction of the Chief Executive Officer, the Risk Coordinator plans, organizes and administers risk management activities with the goal of minimizing the adverse effects on patients and / or losses to the organization. The Risk Coordinator develo ...
Delegation Oversight Clinical Auditor RN II - Los Angeles, United States - L.A. Care Health Plan
Description
Salary Range:
$88, Min.) - $115, Mid.) - $142, Max.)
Established in 1997, L.A.
Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.
We are the nation's largest publicly operated health plan.Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.
Mission:
L.A.
Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
Job Summary
The Delegation Oversight Clinical Auditor RN II is responsible for ensuring that delegates contracted to perform Utilization Management (UM) functions on behalf of LA Care (LAC) is in compliance with all UM regulatory requirements and new legislation through the maintenance of required policies/procedures/workflows/ processes/audit tools necessary to meet the requirements.
It is expected that the Clinical Auditor will utilize a rapid team approach for needed improvements identified through external audits of delegated entities.
This position assist in maintaining continuous quality improvement in the Delegation Oversight Clinical Audit unit ensuring that departmental/divisional and organizational goals are accomplished through overseeing and facilitating compliance of the Plan Partners, Participating Provider Groups (PPG), Specialty Health Plans (SHP), and contracted provider network as managed by the Delegation Oversight Department.
It is responsible, as part of the oversight team, for ensuring compliance of the Plan Partners and/or Participating Physician Groups (PPG) to regulatory, contractual and L.A.
Care requirements. This position is responsible for performing annual and focused audits. This position also acts as a liaison between the Plan Partners and PPGs and L.A. Care Health Plan regarding UM issues.The position assists in improving access and utilization performance of Plan Partners and PPGs by being a resource for best practices and providing continuous feedback.
Additionally, the oversight responsibility of this position includes reporting to management and providing consultation/instructional/coaching recommendations to improve overall compliance of Plan Partners and PPGs with all regulations and standards.
Duties
Continually ensures delegate compliance with UM Policies/Procedures, Letter Templates, Workflows, Processes, and Audit Tools in compliance with all regulatory requirements/new legislation.
Stay abreast of new UM legislation, regulations, or other changes impacting UM in order to put processes in place for compliance.
Prepares the Delegation Oversight Clinical Audit team for internal audits and for conducting PP/PPG audits, developing mechanisms for tracking/ trending of progress for UM/PPG (internal) and PP (external) for compliance with UM standards, and identities system/individual areas for improvement through these processes.
Ensures that the Delegation Oversight Department is continually prepared for external review with staff daily work conducted in a manner that meets regulatory requirements.
Ensures that the Delegation Oversight Clinical Audit unit functions as a team in preparing needed documents for an external review.
Completes annual, focused and periodic audit activities timely and thoroughly including identification of deficiencies, response to mitigation, review and response to CAPs.
Develops and conducts ongoing monitoring activities including but not limited to file reviews and letters and supplemental reports. Present summary results to L.A. Care's UM Committee. Communicates with assigned PP and PPGs on an ongoing basis.
Develop mechanism to track and trend progress of PP and PPG's compliance to UM standards and identify system wide issues.
Duties ContinuedMaintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assists co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions.
Actively identifies and makes recommendations to supervisor ideas to improve the quality effectiveness and efficiency of departmental and health services functions.
Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner.Provide training, education and consultation as necessary to PP and PPGs. Collaborate with other Clinical Auditors on identifying topics and developing agendas for the JOM's and PP visits/communication. Develop and implement procedures to assure compliance with care coordination and documentation of linked and carved out services.
Conducts Interrater Reliability Testing (referral management and oversight) for new staff/physicians and annually or as needed for existing staff/[physicians.
Works with other departments as necessary to facilitate teamwork for creating and/or improving interdepartmental processes to meet regulatory requirements.
Clinical Auditor (Performance Monitoring): In addition to the responsibilities above, the Clinical Auditor (Performance Monitoring) position ensures compliance of the delegates (Participating Physician Groups, Plan Partners and Vendors) with regulatory, contractual and L.A.
This position is responsible for delegation oversight continuous monitoring activities and monitoring corrective action plans from the annual and focused audits.
The position also acts as a liaison between the Plan Partners, PPGs and Vendors regarding Utilization Management (UM) issues; assists in improving access and utilization performance of PPGs by being a resource for best practice and providing continuous performance feedback.
Additionally, the oversight responsibility of this position includes attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings.
It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards.
Clinical Auditor (Behavioral Health): In addition to the duties above, the Clinical Auditor (Behavioral Health) will design an audit program specific to ensuring delegates are meeting behavioral health regulatory requirements.
This Position is responsible for developing and maintaining annual audit tools, policy requirements specific to delegates, and a monitoring program to continually receive and aggregate Behavioral Health specific performance requirements.
The position will act as a liaison between Specialty Health Plans and Plan Partners regarding Behavioral Health issues, assists in improving access and Behavioral Health performance by being a resource for best practice and providing continuous performance feedback.
Additionally, the oversight responsibility includes liasing with internal Behavioral Health units, the Medical Director of Behavioral Health, attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings.
It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards.
Performs other duties as assigned.Education Required
Associate's Degree in Nursing
Education Preferred
Bachelor's Degree in Nursing
Experience
Required:
At least 3-5 years in a clinical setting with at least 3 years in a managed care setting in Utilization Management/Case Management.
Required:
Knowledge of issues pertaining to Medi-Cal and other HMO & IPA contracts, & payers.
Ability to manage and organize large volumes of data.
Knowledge of accreditation entities and their requirements.
Excellent verbal and written communication skills and excellent interpersonal skills.
Good working knowledge of regulatory requirements/standards.
Ability to work independently.
Ability to solve complex issues and identify creative solutions.
Computer ease & literacy with Word, Excel, PowerPoint Skills.
Licenses/Certifications Required
Registered Nurse (RN) - Active, current and unrestricted California License
Licenses/Certifications Preferred
Required Training
Physical Requirements
Light
Additional Information
Salary Range Disclaimer:
The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
L.A. Care offers a wide range of benefits including
Nearest Major Market:
Los Angeles
Job Segment:
Nursing, Behavioral Health, Registered Nurse, Clinical Research, Medical Research, Healthcare