Clinical Audit Specialist – Utilization Management
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Job Description
Clinical Audit Specialist responsible for auditing medical necessity determinations to ensure regulatory compliance. Collaborating with healthcare providers to enhance utilization management practices.
Responsibilities:
- Conduct retrospective and targeted audits of utilization management medical necessity determinations including pre-service, concurrent, and post service reviews.
- Evaluate application of evidence-based clinical criteria (MCG, InterQual) and adherence to medical and administrative policies in utilization management determinations.
- Assess clinical documentation, rationale for determinations, and compliance with regulatory and contractual and accreditation requirements.
- Analyze audit findings to identify trends, inconsistencies, and systemic issues in medical necessity decision-making and utilization management processes.
- Prepare comprehensive audit reports summarizing findings, identified risks, and recommendations for corrective action and process improvement to leadership.
- Collaborate with Medical Directors, UM leadership and UM Operational teams to address complex audit findings.
- Participate in policy review and process improvement initiatives to strengthen the accuracy, consistency, and defensibility of medical necessity determinations.
Requirements:
- Associates of Science (A.S) in Nursing (ASN) required
- Bachelor of Science (B.S) in Nursing (BSN) preferred
- Five (5) years of clinical or related healthcare industry experience required
- Two (2) years Utilization Management/Utilization Review for Commercial, Medicaid, Medicare populations required
- Demonstrated experience applying evidence-based criteria, including MCG and InterQual required
- Managed Care experience required
- Experience conducting retrospective reviews, quality audits, or compliance reviews preferred
- Experience with analysis, data and reporting preferred
Benefits:
- health insurance
- retirement plans
- paid time off
- professional development
- substantial and comprehensive total rewards package
- bonus tied to company and individual performance
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