Performs advanced level and/or managerial professional clinical auditing work. Manage or conduct performance, financial, and compliance audit projects; providing consulting services to organizational management and staff; providing input to development of the annual audit plan; and providing training, coaching, and supervision to audit staff. Maintains all organizational and professional ethical standards. Works independently under general direction with extensive latitude for initiative and independent judgment. Develop, implement and evaluate the quality assurance program within the clinical departments for Medical Management.
- Registered Nurse with a minimum of four to six years clinical experience, current New York State license and/or Connecticut license depending on assignment.
- Bachelors Degree in Healthcare or related field preferred.
- Master’s Preferred
- Experience in auditing or program evaluation, including three years of supervisory or project management experience.
- Previous managed care experience which include administrative responsibilities./ Supervisory experience preferred
- Experience in industry auditing and in supervising and conducting audits in information systems and other areas pertinent to the industry.
- Strong PC skills.
• Manage the performance of audit procedures, including identifying and defining issues, developing criteria, reviewing and analyzing evidence, and documenting client processes and procedures.
• Act as a resource across all clinical departments to ensure understanding of timelines around internal and external auditing and QA functions
• Manage the identification and evaluation of the organization’s risk areas and provide major input to the development of the annual audit plan.
• Provide ongoing monitoring, evaluation, support, and guidance
• Manage the identification, development, and documentation of audit issues and recommendations.
• Manage the conducting of interviews, reviewing of documents, developing and administering surveys, composing summary memos, and preparing working papers.
• Communicate the results of audit and consulting projects via written reports and oral presentations.
• Represents clinical audit on organizational project teams, at management and board meetings and with external organizations.
• Submits periodic written reports, as required
Position Success Criteria:
• Performance will be measured specifically by appropriateness of staffing; case loads, cost of staffing plan, appropriateness of tools for employees, timeliness and appropriateness of response to vendors, providers and members; improved effectiveness and efficiency of the process and member provider and employee satisfaction with the operations of the process.
Must also have the following demonstrated knowledge, skills, and abilities:
• Extensive knowledge of and skill in applying auditing and accounting principles and practices, and management principles and preferred business practices.
• Considerable knowledge of the Standards for the Professional Practice of Internal Auditing and the Code of Ethics developed by The Institute of Internal Auditors.
• Knowledge of management information systems terminology, concepts, and practices.
• Considerable knowledge of industry program policies, procedures, regulations, and laws.
• Skill in conducting quality control reviews of audit work products.
• Skill in collecting and analyzing complex data, evaluating information and systems, and drawing logical conclusions.
• Extensive skill in planning and project management, and in maintaining composure under pressure while meeting multiple deadlines.
• Considerable skill in negotiating issues and resolving problems.
• Skill in using a computer with word processing, spreadsheet, and other business software to prepare reports, memos, summaries, and analyses.
• Considerable skill in effective verbal and written communications, including active listening skills and skill in presenting findings and recommendations.
• Ability to establish and maintain harmonious working relationships with co-workers, staff and external contacts, and to work effectively in a professional team environment.
• Strong problem-solving ability.
• Excellent written and oral communication skills.