Clinical Auditor, Care Management, Registered Nurse
Title: Clinical Auditor, Care Management, Registered Nurse
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 Philadelphia, 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.
As a member of the Corporate Clinical Auditing team, the Clinical Auditor coordinates and completes associate quality audits of clinical staff, focused reviews, and problem identification. Provides coaching and feedback to associates as necessary. Provides routine/scheduled and ad hoc audit reports, including trend identification and root cause analysis. Coordinates development of action plan for identified issues. Participates and assists in the development of necessary protocols, policies and procedures, and operational strategies for Clinical Services. Provides a report tracking compliance with timeliness as mandated by applicable legislative and accrediting organizations, including trend identification and root cause analysis. Coordinates development of action plans for identified issues. Responsible for ongoing development of audit tools to meet business needs. Participates in Quality Reviews and Inter Rater Reliability process as requested. Works with the management team to develop and provide individual and department-level performance improvement plans and activities as well as plan/process follow-up.
- Active and unrestricted RN License.
- 1-2 years of specific clinical knowledge / experience Case Management, preferably within managed care.
- Demonstrated ability to identify trends and conduct root-cause analyses.
- Ability to provide constructive feedback with a focus on improved quality.
- Ability to communicate in a positive/professional manner both orally and written.
- Ability to follow detailed instructions with a high degree of accuracy.
- Ability to work independently; complete tasks in the allotted time frame.
- Strong problem solving skills and decision making skills.
- Experience using EXP, SIR, Jiva, Access, Word, Excel, Outlook.
- Strong knowledge of clinical criteria – InterQual preferred.
- Demonstrated knowledge of plan benefit information and managed care.
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