CQM Non-Clinical Auditor

Position Summary:

The Continuous Quality Monitoring (CQM) team is responsible for ensuring regulatory compliance related to Utilization Management (UM) and Case Management (CM) activities. The CQM auditor reports directly to the CQM Manager. CQM duties include, but are not limited to, performing UM process related internal audits, coordinating Health Plan corrective action responses with the responsible business units, pre-audit preparation for health plan audits, and active involvement in other tasks as assigned by the Continuous Quality Monitoring Manager. The position also requires a thorough understanding of comprehensive UM processes, policies, procedures, report reviews, and quality improvement initiatives. Other traits that are essential for success in this role include a strong work ethic, perseverance, initiative, excellent communication skills, accountability, and comfort in a highly computerized environment.

Essential Duties and Responsibilities include the following:

• Must be familiar with UM regulations and prior authorization processes, as applicable to all lines of business including EAE DSNP, Commercial, Senior, Medi-Cal, etc.
• Must be familiar with UM reports, be able to run certain reports using Report Manager and Tableau.
• Must be proficient in excel and other report formats.
• Review, distribute, draft, provide feedback and follow through completion on assigned Health plan specific CAPs.
• Perform pre-health plan audit file reviews in preparation for health plan audits.
• May drive/present case files during external audits.
• Assigned specific UM process related quality audits which vary in number and audit elements.
• Summarizes quality monitoring audit findings and works with the business units to obtain remediation for identified deficiencies.
• May also analyze root causes and propose quality improvement plans (as applicable).
• Maintain, file, and track automated reports received and internal audits performed.
• Maintain, file, and track health plan CAPs and NON-CAPs.
• May prepare and conduct focus monitoring on specific areas needing improvement based on quality monitoring findings, health plan audit results, and/or executive management requirements.
• Ensures all assignments are completed within required timeframe.
• Ensures all health plan tasks are submitted by the due date with 100% compliance.
• Collaborates with, and reports to UM compliance team, as needed, any compliance or HIPAA related deficiencies. 
• Reviews health plan case files pulled by the liaison team and health plan reporting to ensure HIPAA compliance.
• Works with business units to monitor the effectiveness and efficiency of any process changes made for quality improvement. 
•  Ensures the implementation of new processes to incorporate updated policies & procedures are implemented accurately through reports and case file reviews. 
• Maintains the Continuous Quality Monitoring manager informed of all completed assigned audits, any non-compliance identified during audit review, etc.
• Maintain abreast of all applicable policies and procedures and job aids to ensure a minimum accuracy rate of 95% in all assigned auditing. 
• Maintain continuous quality monitoring department resources and tools updated based on current policy and procedure and job aids.  
• Keep evidence of all quality monitoring audits, assignment, remediation, and projects.
• Maintain organized and updated departmental folders, grids, etc.
• Works with UM business units, under direction from the continuous quality monitoring manager, to monitor UM employee processing performance.
• Attend department meetings, in-services, trainings, and complete acknowledgement within required timeframe.
• Other duties as assigned.

Policies:

• Communicate verbally and in writing through appropriate channels.
• Maintain confidentiality and follow HIPAA policies.
• Follow dress code.
• Use time clock or time sheet appropriately (as applicable).
• Participate in staff meetings.
• Notify supervisor in writing of time off requests.
• Be courteous and promote professionalism.
• Promote organizational goals.
• Be flexible and adaptable.
• Know and follow safety standards.
• Follow attendance policy

The pay range for this position at commencement of employment is expected to be between $30 - $32 Hourly; 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.

Education and/or Experience:

• Graduate from 4 years University with bachelor diploma, preferred.
• At least 3 years of experience in managed care setting with minimum 2 years of UM experience in prior authorization.
• Minimum 1-year of UM supervision or reporting audit experience, preferred.
• Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point).
• Typing 60 words per minute with accuracy.
• Ability to deal with responsibility in 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 with timeliness, 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.
• Must possesses strong verbal & written communication skills.