Provider Auditor Senior at Elevance Health conducting audits on medical claims and ensuring compliance with contracts. Analyzing data and mentoring staff while working in a hybrid environment.
About the role
- Clinical Quality Auditor Lead performing audits and ensuring compliance with quality standards at Elevance Health. Mentoring staff and preparing for oversight audits across various locations in the U.S.
Responsibilities
- Prepares team for oversight audits
- Prepares corrective action plans in response to oversight body's request
- Conducts audits of Quality Management (QM) processes and files
- Writes policies and procedures and assists with development of provider manuals, audit tools, and guidelines
- Responsible for specific QM processes/functions (i.e. compliance, grievances/appeals or HEDIS/quality improvement projects)
- Assists manager with day-to-day monitoring and prioritizing of workflows and activities
- Develops and improves departmental processes and operations
- Monitors goals, performance and processes
- Assists with issues of non-compliance
- Mentors and coaches staff
- Trains new associates and re-trains current associates
- Monitors and prioritizes workflows
- Serves as a resource and a subject matter expert
Requirements
- Requires BS in nursing, health sciences, health management or a related clinical field
- Minimum of 5 years of experience in utilization management, quality assurance and/or regulatory/accreditation standards/audits
- Minimum of 3 years of quality management experience
- Current active unrestricted license such as an RN, LCSW, LMSW, LMHC, LPC, LBA
- Strong oral, written and interpersonal communication skills
- Problem-solving skills
- Facilitation skills
- Analytical skills
- For associates working within Puerto Rico: current PR health certificate and current PR Law 300 certificate are required
Benefits
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical benefits
- dental benefits
- vision benefits
- short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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