Wage Range: $65,000/year to $75,000/year
Job Summary
The Credentialing Auditor is responsible for the audit and oversight of the Credentialing processes both internally and for the Plan’s FDRs. Lead the company’s efforts to meet regulatory and compliance requirements and collaborate with internal departments and delegated entities.
*This position is remote with occasional onsite meetings*
Functions & Job Responsibilities
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Inform various departments within Clever Care and delegates of Clever Care of any changes to regulatory requirements in relation to credentialing and re-credentialing.
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Conduct pre-delegation Credentialing audits for applicable areas to ensure that delegates are able to perform the delegated activities prior to delegation.
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Conduct annual Credentialing delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the agreement.
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Conduct Clever Care internal Credentialing audit to ensure we comply with CMS requirements.
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Develop, implement, and manage corrective action plans.
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Monitor, analyze, aggregate and report on data reported to the Plan.
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Provide leadership and direction in communicating and monitoring policies, procedures, practices, programs, and processes.
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Participate and/or lead CMS Mock-Audits and train associates.
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Lead audit activities and report results to leadership team.
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Collaborate on the audit program for the Plan.
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Maintain an up-to-date knowledge of CMS requirements
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Collaborate with other departments on issues, audits, and corrective actions.
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Consult with General Counsel/lawyer, as needed, to identify and resolve legal issues and concerns.
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Perform functions according to established policies and procedures, regulatory requirements, and applicable professional standards.
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Provide customers, internal and external, with professional service and demonstrates core and leadership behaviors.
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Other duties as assigned.
Qualifications
Education & Experience:
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Associate or bachelor’s degree in healthcare or equivalent preferred.
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Valid driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for onsite audit work.
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One (1) to three (3) years of Credentialing or Medicare audit experience.
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Minimum two (2) years’ experience with Credentialing and Re-Credentialing audit processes.
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Advanced knowledge of Medicare Advantage CMS and California DMHC regulations.
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Advanced knowledge of HIPAA regulations required.
Skills:
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Strong organizational skills: Ability to multitask and problem solving.
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Experienced at interfacing with national and regional CMS offices.
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Presentation skills for training large and small groups.
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Excellent verbal and written communication skills and ability to maintain positive relations with Plan partners.
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Analytical and critical thinking skills are required.
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Exhibit initiative and ability to assume responsibility and maintain confidentiality.
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Advanced computer skills and experience with Microsoft Office Products.
Physical & Working Environment.
Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
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Must be able to travel when needed or required
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Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
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Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.
Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.
Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.
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