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Auditor, Quality Monitoring

2 months ago

Northridge, United States Regal Medical Group Full time
Job Description

Position Summary:

Prior Authorization Quality Monitoring Nurse Auditor reports to the Director of Prior Authorization and performs Prior Authorization Process Quality Monitoring to assure the regulatory compliance and quality of process in daily Prior Authorization activities with minimal to moderate supervision. The Prior Authorization Quality Monitoring Specialist Nurse will work closely with the prior authorization directors/Managers, Data Analysts and UM compliance to promote high quality, efficient and effective prior authorization process. This position requires knowledge of comprehensive prior authorization policies/ processes procedures, UM audit and quality improvement.

Essential Duties and Responsibilities Include the following:

  • Prior Authorization Quality Monitoring Specialist Nurse must be familiar with UM regulations and prior authorization process.
  • Prior Authorization Quality Monitoring Specialist Nurse is assigned specific projects to monitor and audit the daily prior authorization activities through reports and case files review.
  • Summarize the quality monitoring findings, analyze root causes and propose of quality improvement plans.
  • Prepares and conducts focus monitoring to the areas needs to be improved based on daily monitoring findings, health plan audit results, and executive management requirements.
  • Work with decision support to maintain and improve the prior authorization monitoring reports.
  • Ensure all assigned projects being completed within required timeframe and report to Prior authorization Compliance Director.
  • Collaborate with UM compliance team to ensure any focus audited area being monitored, and the quality of process being tracked.
  • Work with operational teams to monitor the effectiveness and efficiency of the process change made for quality improvement.
  • Ensure new process procedure being implemented accurately through reports and case files review.
  • Attend prior authorization huddle meetings to know any updates and requirement in prior authorization process.
  • Report issues found to prior authorization compliance director based on findings.
  • Review updated policy and procedure, be able to update the quality monitoring tool based on the policy and procedures. .
  • Keep all evidence of quality monitoring projects.
  • Maintain and track daily reports received from decision support team.
  • Report issues related to internal processes (i.e. timeliness issues) to the Director.
  • Work with prior authorization team under direction from prior authorization compliance director to monitor prior authorization employees processing performance.
  • Attend department meetings, in-house service, trainings and complete acknowledgement within required timeframe.
  • Other duties as assigned.
The pay range for this position at commencement of employment is expected to be between for LVN's $37.50 - $40 or for RN's $45 - $50 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.

The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.

Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.

As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.

Full Time Position Benefits:

The success of any company depends on its employees. For us, employee satisfaction is crucial not only to the well-being of our organization, but also to the health and wellness of our members. As such, we are firmly dedicated to providing our employees the options and resources necessary for building security and maintaining a healthy balance between work and life.

Our dedication to our staff is evident in our comprehensive benefits package. We offer a very generous mixture of benefits, including many employer-paid options.

Health and Wellness:
  • Employer-paid comprehensive medical, pharmacy, and dental for employees
  • Vision insurance
  • Zero co-payments for employed physician office visits
  • Flexible Spending Account (FSA)
  • Employer-Paid Life Insurance
  • Employee Assistance Program (EAP)
  • Behavioral Health Services
Savings and Retirement:
  • 401k Retirement Savings Plan
  • Income Protection Insurance
Other Benefits:
  • Vacation Time
  • Company celebrations
  • Employee Assistance Program
  • Employee Referral Bonus
  • Tuition Reimbursement
  • License Renewal CEU Cost Reimbursement Program
  • Business-casual working environment
  • Sick days
  • Paid holidays
  • Mileage
Employer will consider for employment qualified applicants with criminal histories in a manner consistent with the requirements of the LA City Fair Chance Initiative for Hiring Ordinance.

Requirements

Education and / or Experience:
  • Graduate from an accredited school for Nursing (LVN or RN).
  • Current and maintains California Nursing License.
  • Three to five (3-5) years of clinical experience in a Managed Care/Medical Group required.
  • Two to three (2-3) years of recent utilization management experience required.
  • Minimum one year (1) year of recent UM supervision/audit experience required.
  • Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point).
  • Advanced in excel
  • Typing 60 words per minutes with accuracy.
  • Ability to deal with responsibility with confidential matters.
  • Must have strong analytical, creative problem solving, and organizational skills.
  • Ability to work in a multi-task, high stress environment.
  • Ability to strategize effectively, execute within timelines, and deliver quality results
  • Ability to thrive in a fast-paced environment where flexibility and being proactive are essential
  • Must be able to handle multiple projects at one time, reset priorities day-to-day to meet deadlines, and know when to ask for assistance and direction when working with conflicting priorities.
  • Must be self-motivated, pleasantly aggressive and realistically ambitious and have high personal ethics.
  • Must have the ability to work with all levels of management and have the ability to develop positive working relationships with different divisions in the company.