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Compliance Auditor (clinical)

This job is available in 1 locations

Compliance Auditor (clinical)

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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Must live in or near Mecklenburg County!

Position Purpose: Lead, monitor and evaluate the performance of national delegated vendors according to CMS, NCQA, Federal and State requirements.

  • Lead compliance audits of vendors. Identify audit scope and required audit tools. Ensure audit results are appropriated compiled and accounted for within designated audit tools
  • Manage, audit, and monitor both internal and external vendors against CMS, contractual, Federal, State, and NCQA standards
  • Review vendors documented processes against contractual, Federal, State, CMS, and NCQA standards
  • Identify process gaps and deficiencies and communicate audit observations, recommendations, and process improvement opportunities
  • Develop and implement quality improvement and corrective action plans based on risk analysis, audit findings, and vendor performance
  • Develop audit tools based on contracted services with vendors and requirements defined by CMS, State, Federal, Medicaid and/or NCQA guidelines
  • Maintain documentation on vendor performance and provide reports to subsidiaries as required for audits and risk assessments. Lead vendor performance oversight meetings with impacted business owners and vendors
  • Utilize clinical knowledge to determine audit findings and in answering counterclaims
  • Train internal audit participants/business owners on audit tools and Medical Management criteria including CM, DM, and UM
Education/Experience: Bachelor’s degree in a clinical field or equivalent experience. 4+ years of combined clinical and compliance or auditing experience in a healthcare environment. Familiarity with Health Insurance Marketplace, Medicaid and Medicare managed care practices and policies preferred.

Licensure/Certifications: Current state RN license required. Valid driver’s license.Pay Range: $67,400.00 - $121,300.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law. Total compensation may also include additional forms of incentives.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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