Care Management Clinical Reviewer II

Job Summary

The Care Management Clinical Reviewer II is responsible for supporting the Care Management (CM) team. This includes monthly individual staff audits (or more frequent per business need), administrative review of policies and procedures for Care Management, Specialty Health Plan/Vendors, Plan Partners, and other entities, if necessary, to ensure compliance with local, State, Federal and National Committee on Quality Assurance (NCQA) regulations, statues and guidelines. The position also contributes toward administrative file reviews/audits and program descriptions. The position is responsible for preparing the individual staff audit findings, documentation of deficiencies as well as developing final staff reports for the Care Management Department Directors and supervisors of the audited resources. The position is also responsible for developing Compliance Department corrective action plans to address deficiencies identified by other departments conducting programmatic level audits. The position reports to the Care Management Services Director and collaborates with the Clinical Assurance, Medicare Operations, Compliance and other departments as needed to ensure Compliance and quality in Care Management operations.

Duties

Conducts monthly individual staff audits to measure individual level performance and compliance. Audits include regulatory, procedural and clinical components to be audited. Collaborates with CM leadership to implement and monitor individual CAPs and/or PIPs as necessary.  Conducts administrative review of policies and procedures implemented by the CM department and by Vendors to comply with local, State, Federal and NCQA regulations, statues and guidelines. Ensure that besides complying with the laws and regulations, that specific functions and projects are carried out to achieve positive healthcare outcome for L.A. Care Membership.  Responsible for the administrative review of policy and procedures using objective criteria for review and where policy nuances are utilized; peer to peer (auditor to auditor) consult is advised.

Coordinates and gathers documentation in order to respond to audits conducted either internally or externally. 

Organize and perform file review process in accordance with given criteria to include collection & verification of supporting documentation, recording received information in appropriate tracking systems, and communicating end results of requests in writing and/or verbally. 

Documentation and reporting of results to CM Leadership and other stakeholders as applicable. 

Perform other duties as assigned. 

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 3 years of experience in documentation, reporting, and auditing in a healthcare or managed care environment.

Care Management experience in a managed care setting. 

Experience with Centers for Medicare and Medicaid Services (CMS) and California Department of Health Care Services (also called the State) (DHCS) regulatory requirements and NCQA. 

Skills

Required:
Excellent verbal and written communication skills.

Excellent interpersonal skills.

Good working knowledge of regulatory requirements/standards.

Managed health care experience.

Proficiency with Microsoft (MS) Office Application, such as MS Word, Excel, and PowerPoint.

Ability to work independently.

Ability to solve complex issues and identify creative solutions.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Additional Information