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Medical Management Auditor - UM Medical Management

Latham, New York Apply Now Job ID 009ZS Category Medical Management Organization Fidelis Care Schedule Full-time
Description:

Position Purpose: Responsible for the auditing of corporate, health plan, and specialty company staff related to clinical systems entry and/or processes

·  Develop and maintain the audit process and tools related to: authorizations, appeals, quality events, and case management in CCMS; interrater reliability related to InterQual; and data entry into the credentialing subsystem

·  Develop and maintain the audit schedule

·  Audit staff as outlined in the system auditing policies

·  Train audit staff at the health plan in the use of audit process and tools

·  Facilitate compliance with the auditing process

·  Act as a consultant related to system auditing to others in the unit, department and health plan

·  Work with staff to identify and resolve authorization load error report system problems

·  Coordinate auditing outcomes with the Trainer to identify, develop and publish corrective actions/educational material related to audit errors

·  Coordinate auditing outcomes and system maintenance with the Sr. Clinical Systems Specialist to resolve or enhance clinical systems

·Ability to travel

Qualifications:
Education/Experience: Bachelor’s degree in related field or equivalent experience. 3+ years of related experience.

License/Certification: Current state nursing license.

For Sunshine State Health Plan & Fidelis Care only: State unrestricted license as Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), Registered Nurse (RN), or Licensed Psychologist (Ph.D. or Psy.D.)

*Registered Nurse license strongly preferred.


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