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Clinical Quality Management Auditor
2 months ago
We are seeking a skilled LPN Auditor to join our Clinical Quality Management team at UnitedHealthcare. As a key member of our team, you will be responsible for gathering and auditing medical records from contacted medical providers, analyzing and tracking results, and recommending quality improvement plans.
Key Responsibilities- Review and audit Medicaid (AHCCCS) Electronic Visit Verification (EVV) providers and medical records regarding AHCCCS AMPM requirements around EVV
- Review, audit, and evaluate documentation of medical records
- Follow relevant regulatory guidelines, policies, and procedures in reviewing clinical documentation
- Prioritize providers for medical chart review according to collaboration with other Health Plans
- Identify incomplete/inconsistent information in medical records and label missing measures/metrics/concerns
- Review relevant tool specifications to guide chart review
- Review/interpret/summarize medical records/data to address any quality of care questions
- Verify necessary documentation is included in medical records
- Maintain HIPAA requirements for sharing minimum necessary information
- Based on review of clinical data/documentation, identify potential quality of care issues (e.g., variations from standard practice potentially resulting in adverse outcomes) and potential fraud/waste/abuse
- Refer issues identified to relevant parties (e.g., review committee, Case Management, Medical Directors) for further review/action
- Discuss with provider offices to address and request corrective action plans
- Educate provider representatives/office staff to address/improve auditing processes
- Educate providers on proper medical record documentation for regulatory compliance
- Educate providers offices on specifications/measures
- Explain/convey technical specifications regarding action plans/follow up
- Explain how provider scores are calculated/determined
- High School Diploma/GED (or higher)
- Active and unrestricted LPN license in the state of Arizona
- 3+ years of experience in the Medicaid health field including provider interactions
- 2+ years of experience reviewing medical record charts/documentation and writing regulatory reports
- Intermediate level of proficiency with software applications that include, but are not limited to, Microsoft Word, Excel, and Teams
- Reliable transportation for field visits
- Ability to travel 50% for the position throughout Arizona when business requires
- Reside in Arizona
At UnitedHealthcare, we offer a comprehensive benefits package, including paid time off, medical plan options, dental, vision, life, and AD&D insurance, 401(k) savings plan, education reimbursement, employee discounts, and more.
We are an equal employment opportunity/affirmative action employer and welcome applications from diverse candidates. We are a drug-free workplace and require a drug test before beginning employment.
