[Hiring] Clinical Data Audit Consultant @Centene Corporation

Role Description

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Registered Nurse - Must be Licensed in CA

Pacific Time Zone Work Hours

Position Purpose:

• The Clinical Data and Audit Consultant is responsible for the clinical content component of all data collection, account implementations, and audit activities for Clinical Operations to ensure high-quality tracking and performance of the service teams.
• The Consultant gathers and analyzes data, creates workflows, coordinates internal and external audits, and analyzes and documents business processes to meet all clinical, procedural, account, and regulatory requirements.
• Demonstrates regular, reliable and predictable attendance.
• Leads various data analysis projects to examine and define potential clinically related issues and track productivity and quality measures.
• Reviews, analyzes, and interprets data for required HEDIS, URAC, NCQA compliance, and related reporting for clinical service teams.
• Interprets clinical data that does not conform to established/approved, required specifications, including Unity Reports, and assists in corrective action processes.
• Addresses and participates in training of clinical staff resulting from data tracking and analysis efforts.
• Identifies, evaluates, recommends and documents clinical business needs and objectives, operational processes and procedures, problems and requirements.
• Produces documentation, including project plans, analytical reports, decision backup, information research reports, training plans, business justifications, graphics, workflow and business process models.
• Recommends operational and process improvements based on efficiencies and available technologies.
• Maintains a repository of performance and audit metrics, and generates management reports illustrating statistical data, text, workflows, and graphics.
• Conducts secondary research using a variety of publications, services and health statistic databases.
• May also be assigned lower level management functions and back up supervisors on clinical team.
• Works with other departments to identify and document business requirements, workflow, policies and procedures.
• Organizes and compiles cases for all External Health Net, NCQA, URAC, and Account Audits.
• Participates in Quarterly Health Net Regulatory Audit meetings to assist Clinical Directors.
• Supports Clinical Supervisors in tracking of monthly Care Manager audit results.
• Works with Data Analysis Department to design data pulls.
• Assists with generating HLOC and Outpatient Cost of Care and Target Outlier Reports including trend analysis.
• Supports staffing analysis with current and forecasted requirements.
• Investigates current regulations, interprets findings, and makes recommendations to Healthcare Services teams.
• Conducts complex trend analysis and, based on analysis, creates Corrective Action Plans, and presents recommendations to business teams across department to improve performance.
• Other duties as required.
• Performs other duties as assigned.
• Complies with all policies and standards.

Qualifications

• BA/BS in Psychology, Nursing or other related clinical field; Masters in Social Work, Counseling, Nursing, or related field preferred.
• Three to five years case management or related clinical experience.
• Two to three years experience conducting business studies, recommending solutions and/or business analysis, preferably in Healthcare.

Requirements

• Licensed Clinician and/or RN required. Must have and maintain current, valid and unrestricted clinical license.

Benefits

• Competitive pay.
• Health insurance.
• 401K and stock purchase plans.
• Tuition reimbursement.
• Paid time off plus holidays.
• Flexible approach to work with remote, hybrid, field or office work schedules.