Compliance Auditor (clinical)

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.
 

Position Purpose: Lead, monitor and evaluate the performance of national delegated vendors according to CMS, NCQA, Federal and State requirements.

• Manage, audit, and monitor both internal and external vendors against CMS, contractual, Federal, State, and NCQA standards
• Review vendors documented processes against contractual, Federal, State, CMS, and NCQA standards
• Identify process gaps and deficiencies and communicate audit observations, recommendations, and process improvement opportunities
• Develop and implement quality improvement and corrective action plans based on risk analysis, audit findings, and vendor performance
• Maintain documentation on vendor performance and provide reports to subsidiaries as required for audits and risk assessments
• Utilize clinical knowledge to determine audit findings and in answering counterclaims
• Train internal audit participants/business owners on audit tools and Medical Management criteria including CM, DM, and UM
• 50% travel required

Must reside in SC

Education/Experience: Bachelor’s degree in a clinical field or equivalent experience. 4+ years of combined clinical and compliance or auditing experience in a healthcare environment. Familiarity with Health Insurance Marketplace, Medicaid and Medicare managed care practices and policies preferred.

Licensure/Certifications: Current state RN license required. Valid driver’s license.

Pay Range: $68,700.00 - $123,700.00 per year

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules.  Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status.  Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act