Compliance Nurse Auditor

1 week ago

Santa Barbara, California, United States CenCal Health Full time
Job Summary

Under the direction of the Audit Manager, this position conducts audit activities of varying complexity and supports initiatives related to CenCal Health's audits, monitoring, and oversight program. The role involves performing routine and complex audit activities, reviewing medical records, and proposing recommendations for improvement.

Duties and Responsibilities
  • Conduct compliance audit activities, including reviewing medical records, documenting results, and developing recommendations for improvement.
  • Review clinical processes against regulatory requirements and NCQA standards.
  • Conduct regulatory research to identify gaps and provide interpretation of clinical requirements and regulations.
  • Develop audit scope and maintain audit tools based on regulatory compliance.
  • Write clear and concise audit reports based on audit results.
  • Assist in development and implementation of quality improvement plans and corrective action plans.
  • Conduct routine monitoring activities to ensure compliance with regulatory and contractual requirements.
  • Prepare and send out audit announcement memos.
  • Prepare audit programs and conduct audits of assigned areas.
  • Perform and coordinate follow-up audits to determine if management has taken action to mitigate risks.
  • Provide independent evaluations and assist with maintenance of operational controls.
  • Train internal audit participants on audit process and tools.
Qualifications
  • Audit experience with DHCS, CMS, DMHC, and/or NCQA and an understanding of clinical audit standards and requirements.
  • Excellent written and verbal communication skills.
  • Experience researching, compiling, and organizing information from various sources.
  • Strong organizational skills and attention to detail.
  • Ability to accurately apply and interpret clinical guidelines.
  • Ability to work productively with all Plan staff.
  • Ability to coordinate work between departments.
  • Ability to work with minimal supervision, both independently and in teams.

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