Utilization Management Auditor Job at Devoted Health
At Devoted Health, we’re on a mission to dramatically improve the health and well-being of older Americans by caring for every person like family. That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of all-in-one healthcare company — one that combines compassion, health insurance, clinical care, and technology. We want to throw the long ball with people we love for a cause we believe in. Life is short. Join us.
Job Description
A bit about this role:
As a Clinical Auditor, you'll have the opportunity to make a difference in the lives of our members. You'll be responsible for performing regulatory, accreditation and operational audits to document compliance with standards, operational and performance improvement objectives as outlined by Management. Our Clinical Auditor is committed to integrity and excellence and facilitating onboarding and training activities to maintain compliance and improve outcomes. Our ideal Clinical Auditor is caring, compassionate and solutions-oriented, and is enthusiastic about providing an outstanding experience for Devoted Health’s members.
Responsibilities will include:
As a Clinical Auditor, you'll have the opportunity to make a difference in the lives of our members. You'll be responsible for performing regulatory, accreditation and operational audits to document compliance with standards, operational and performance improvement objectives as outlined by Management. Our Clinical Auditor is committed to integrity and excellence and facilitating onboarding and training activities to maintain compliance and improve outcomes. Our ideal Clinical Auditor is caring, compassionate and solutions-oriented, and is enthusiastic about providing an outstanding experience for Devoted Health’s members.
Responsibilities will include:
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Develops audit tools and conducts audits as assigned to assist in management’s documentation of compliance with regulatory, accreditation and operational process improvement standards.
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Examines and compares records and processes with required standards for accuracy and completeness in meeting currently established regulatory, accreditation and/or operational process improvement project standards. Assists in the review of new regulatory and accreditation standards on an annual or as needed basis.
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Prepare summary of audit findings with appropriate notification to management of issues in a concise and well-documented format, with a gap analysis as appropriate and proposed action plans for improvement.
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Conducts follow-up reviews to assess and verify effectiveness of any implemented action plans.
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Communicates significant audit findings to management in a timely manner following the completion of audit tasks. Prepares and submits documentation of required follow-up reviews on previous audit results in a timely manner.
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Develops and conducts effective Utilization Management orientation and training programs on operational systems and creates business practices to ensure consistent performance within plan, regulatory and accreditation standards.
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Collaborates with management and Utilization Management staff to identify and assess learning needs impacting operational effectiveness.
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Creates and conducts effective training programs on operational best practices & clinical training to improve staff morale, member care coordination and operational efficiency.
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Assists with the timely development and revision of training materials, manuals, and evaluation materials. Maintains detailed records of training programs and participants and generates accurate statistical reports.
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Develops and coordinates the presentation of continuing education activities specific to managed care principles. Prepares materials as needed to specific cases for learning opportunities in managed care principles on real-time cases.
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Maintains technical proficiency and remains current with the latest developments, advancements and trends in utilization management compliance.
Attributes to success:
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A desire to make a change in the healthcare experience: you love to serve and make a difference
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Proven success in building relationships
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The ability to adjust your tone and approach to different people
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The ability to articulate and break down complex information. Adaptability and comfort in a dynamic, startup environment
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Transparency in your work - what’s going well and what’s not
Desired skills and experience:
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Ability to work in a startup, fast paced environment
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An unrestricted RN or LVN/LPN license, or Bachelor’s degree (preferred)
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A minimum of 4 years within Medical Management, utilization management at a Health Plan
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The ability to comfortably multi- task and pivot priorities as needed: you’ll be listening, talking and typing all at the same time
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Team player mentality with a can-do attitude
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Understanding of CMS guidelines, MA requirements, and SNP (Special Needs Plans) Care Coordination Standards
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Comply with industry specifications, standards, regulations, and laws.
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Review operational practices
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Documenting compliance-related processes and maintaining records.
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Monitoring compliance and facilitating interventions to manage risks.
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Keeping abreast of regulatory changes and developments in the regulatory environment.
Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.
As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.
COVID-19 Vaccination Requirement: Where permitted by applicable law, candidates must have received or be willing to receive the COVID-19 vaccine by date of hire to be considered. The Company will provide reasonable accommodations to qualified employees with disabilities or for a sincerely held religious belief, practice, or observance.
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