Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Clinical Auditor
Summary of Position:
Manage, monitor and track compliance of the UM, CM, MRU, MCRU adherence to Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, , utilization management. Participate in planning and implementing strategies that provide direction and subsequent monitoring of the UM, CM, MRU, MCRU team functions including assessment of potential new processes and existing processes. Interact with and educate the UM, CM, MRU, MCRU management team, to review Corrective Actions Plans from/for Compliance and ensure that they are being managed and adhered to. Oversee the monthly Key Performance Indicator (KPI), auditing the results and providing feedback to the UM, CM, MRU, MCRU areas on areas that are not meeting Compliance thresholds. Work with Reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards. Work with the Delegates and vendors.
Responsibilities:
- Audit, monitor and track compliance of the UM, CM, MRU, MCRU teams adherence to the Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, utilization management,. This entails reviewing reports against regulatory requirements, looking for trends, notifying management of any trends, and then tracking their responses/actions to ensure the negative trends do not continue.
- Participate in planning and implementing strategies that provide direction and subsequent monitoring of the UM, CM, MRU, MCRU team functions including assessment of potential new processes and existing processes.
- Track UM, CM, MRU, MCRU compliance using the dashboard/matrix, and other organizational and department tools including loading material for organizational use onto Sharepoint.
- Oversee and track audit reports and responses, including changes to any policies, procedures and other pertinent information (such as training and attestations) in a central corporate location This includes but is not limited to tracking and maintaining organization of documents including audit schedule, dashboard matrix, and team audit tools, CAPS, completed and incomplete audits, and other functions and processes to ensure efficiency within the Plan.
- Work with Reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards.
- Uploading reports for Compliance on a monthly basis.
- Work with the Delegates/vendors and the top 5% report to request/review members that are being submitted for Case Management
Qualifications:
- Associates degree desired, Bachelor’s degree preferred
- Years of experience can be substituted for years generally required for a degree
- Active, unrestricted Nursing License (RN or LPN) required
- Possess at least 4 to 6 years of experience in a managed care environment including familiarity with auditing, accreditation, compliance, Quality, or delegation or UM experience required
- Knowledge of accreditation standards, and regulatory standards such as NYSDOH and CMS preferred
- Experience within an operation that addresses complex relationships and multiple stakeholders with conflicting goals and priorities with diverse needs and skill sets required
- Strong problem solving and negotiating skills paired with strong attention to detail required
- Knowledge of utilization management process, case management process and, accreditation and regulations as applicable to managed care required
- Exercise discretion and maintain confidentiality required
- Ability to independently manage multiple tasks or projects simultaneously to successful completion required
- Remain highly organized and adhere to processes, policies and procedures required
- Excellent interpersonal skills, professionally communicate verbally in person, via telephone, and in writing
- Proficient in understanding and in use of Word, Excel, SharePoint, PowerPoint and Outlook, including excellent working knowledge of MS Office applications preferred
- Highly self-motivated and self-directed independent thinker while being a resource and strong and flexible team player required
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.