Clinical Auditor, Utilization Management, Registered Nurse, REMOTE

AmeriHealth Caritas Health Plan Remote
utilization utilization management management registered nurse nurse remote identification team root cause analysis analysis management managed care driver's license
November 24, 2022
AmeriHealth Caritas Health Plan
Philadelphia, Pennsylvania
  • As a member of the Corporate Clinical Auditing team, the Clinical Auditor coordinates and completes associate quality audits of clinical staff, focused reviews, and problem identification.
  • Provides coaching and feedback to associates as necessary.
  • Provides routine/scheduled and ad hoc audit reports, including trend identification and root cause analysis.
  • Coordinates development of action plan for identified issues.
  • Participates and assists in the development of necessary protocols, policies and procedures, and operational strategies for Clinical Services.
  • Provides a report tracking compliance with timeliness as mandated by applicable legislative and accrediting organizations, including trend identification and root cause analysis.
  • Coordinates development of action plans for identified issues.
  • Responsible for ongoing development of audit tools to meet business needs.
  • Participates in Quality Reviews and Inter Rater Reliability process as requested.
  • Works with the management team to develop and provide individual and department-level performance improvement plans and activities as well as plan/process follow-up.
  • Current and unrestricted Registered Nurse licensure.
  • 1-2 years of specific clinical knowledge experience in Utilization Management, preferably within a managed care organization.
  • 3-5 years of credentialing, delegation, or relevant provider data experience preferred.
  • Experience using EXP, SIR, Jiva, Access, Word, Excel, Outlook.
  • Strong knowledge of clinical criteria, preferably Interqual.
  • Demonstrated knowledge of plan benefit information and managed care.
  • Demonstrated ability to identify trends and conduct root-cause analyses.
  • Ability to provide constructive feedback with a focus on improved quality.
  • Ability to communicate in a positive/professional manner both orally and written.
  • Ability to follow detailed instructions with a high degree of accuracy.
  • Ability to work independently; complete tasks in the allotted time frame.
  • Strong problem solving skills and decision making skills.
  • This position may require up to 25% travel.
  • Current state driver's license and car insurance.

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