Clinical Auditor LVN D-SNP, Bakersfield, CA

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Clinical Auditor LVN D-SNP

KHS Family Health Care, Bakersfield, California, United States of America Req #2646

We appreciate your interest in our organization and assure you that we are sincerely interested in your qualifications. A clear understanding of your background and work history will help us potentially place you in a position that meets your objectives and those of the organization. Qualified applicants are considered for positions without regard to race, color, religion, sex (including pregnancy, childbirth and breastfeeding, or any related medical conditions), national origin, ancestry, age, marital or veteran status, sexual orientation, gender identity, genetic information, gender expression, military status, or the presence of a non-job related medical condition or disability (mental or physical).

KHS reasonably expects to pay starting compensation for the position of Clinical Auditor D-SNP in the range of $32.05 - 40.86 hourly.

*Hybrid Position*

About us

Kern Health Systems (KHS) is dedicated to improving the health status of our members through an integrated managed health care delivery system.

About the role

The Clinical Auditor D-SNP will monitor regulatory compliance of clinical functions related to the D-SNP line of business as assigned under the direction of the Director of Delegation Oversight by conducting routine monitoring and auditing of both internal and external partners ensuring compliance with Medicare, Medi-Cal and California Integrated Care Management requirements.

Essential Duties and Responsibilities

Under the direction of the Director of Delegation Oversight:

• Assists in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Manages multiple concurrent and retrospective audits, monitors efforts and related projects independently.
• Makes recommendations around objectives and scope of regulatory adherence and ensures effective and efficient audit execution.
• Research regulations and informs delegates of any changes to regulatory requirements.
• Conducts mock audits of delegated clinical functions using audit tools and develops corrective action plans to address any identified issues.
• Performs readiness and annual oversight audits for applicable areas ensuring the entity’s ability to perform activities prior to contract execution and in accordance with the agreement.
• Collects and summarizes performance data and presents findings to all applicable committees.
• Participates in workgroups that address both clinical and non-clinical activities that the plan must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC) and/or other applicable regulatory agency.
• Participates in committee meetings.
• May be required to complete D-SNP related utilization management, care management or transitions of care functions as necessary should the delegate be unable to meet the contractual requirements of their agreement.
• Completes other projects and duties as assigned.

Employment Standards

Education, Experience and Licensure:

• Current, unrestricted Licensed Vocation Nurse (LVN), required.
• 2 years of experience in delegate/internal auditing and utilization management to include experience in a health care delivery system, health plan, medical group, or hospital required.
• Bachelor’s degree in a Healthcare related field preferred
• Professional certification in Care Management, Utilization Management and/or Managed Care preferred.

Knowledge:

• Working knowledge of utilization management and care management principles.
• Ability to analyze data and identify trends and actionable statistics.
• Knowledge of Medicare/MediCal Managed Care Plans
• Working knowledge of how to apply evidenced based utilization management criteria with clinical oversight from the Director of Delegation Oversight and/or the D-SNP Medical Director.
• Able to manage projects/initiatives to improve program performance
• Able to communicate positively, professionally and effectively with others; teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Able to perform mathematical calculations and calculate simple statistics correctly.
• Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Comprehend and analyze statistical reports.
• Computer proficiency; Microsoft Office Suite and experience with care management and utilization management software platforms.

Ability to:

Communicate effectively, both verbally and in writing, with internal and external stakeholders; adapt to a rapidly evolving work environment; work independently and manage multi-task responsibilities with a high level of attention to detail; identify challenges and develop strategies to address; prioritize workload.

Other:

Required travel up to 25%. Possession of valid California Driver’s License and proof of valid State required auto liability insurance.

We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis.

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