CQM Nurse Auditor

Position Summary: The Continuous Quality Monitoring Nurse Auditor reports to the Manager of Continuous Quality Monitoring and performs utilization management (UM) process related quality monitoring to assure regulatory compliance and quality of process in daily utilization management activities with minimal to moderate supervision. The Continuous Quality Monitoring Auditor will work closely with the UM business units on elements that do not require clinical decisions to promote high quality, efficient and effective UM processes. This role also needs to support any projects directed by the Continuous Quality Monitoring manager. This position requires a progressive knowledge of comprehensive UM processes, policies & procedures, UM reports review, and quality improvement. Essential Duties and Responsibilities include the following: Continuous Quality Monitoring Auditor must be familiar with UM regulations and prior authorization processes. Must be familiar with UM reports, be able to run certain reports using Report Manager and Tableau, as well as be proficient in excel and other report formats. 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. 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 assigned projects/quality monitoring audits are completed within required timeframe. Collaborates with, and reports to UM compliance team, as needed, any compliance or HIPAA related deficiencies. Reviews health plan case files and 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 directed by management. The pay range for this position at commencement of employment is expected to be between LVN's $37.50 to $40 to RN's $45 - $50 per hour; 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. Requirements: Education and / or Experience: Graduate from an accredited school for Nursing (LVN or RN). Current and maintains California Nursing License. At least 3 years of experience in managed care setting. Clinical license/experience preferred. Minimum 2 years of utilization management experience in prior authorization and/or reporting. Minimum 1 year 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. Compensation: $37.50 to $40 to RN's $45 - $50