RN Clinical Auditor- Bakersfield 1.2

Description

Location: Bakersfield, CA 93309

Classification:

Full-Time (Non-Exempt)

Benefits:

· Medical

· Dental

· Vision

· Simple IRA Plan

· Employer Paid Life Insurance

· Employee Assistance Program

Compensation:

The initial pay range for this position upon employment commencement is expected to be between $96,408.00 and $120,494.4 annually, translating to $46.35 to $57.93 per hour. However, the base pay offered may be adjusted based on individualized factors, including the candidate's education, certifications, skills, and experience. We value exceptional talent and strive to provide competitive compensation packages tailored to attract and retain top candidates like yourself.

Position Summary:

The RN Auditor for the Enhanced Care Management (ECM) Program is responsible for providing clinical oversight in compliance with the Department of Health Care Services (DHCS) requirements. This role ensures the accuracy, completeness, and regulatory compliance of member charts, assessments, care plans, and care activities within the ambulatory case management setting. The RN Auditor plays a key role in supporting continuous quality improvement, ensuring adherence to ECM program protocols, and fostering interdisciplinary collaboration to deliver high-quality, patient-centered care for Medi-Cal beneficiaries.

Job Duties and Responsibilities:

• Perform detailed audits of member charts to ensure documentation meets DHCS, Health Plans, and internal policy standards for accuracy, consistency, and completeness.

• Ensure care plans and assessments reflect appropriate interventions and comply with ECM program protocols and state guidelines.

• Identify documentation or care coordination gaps, providing timely feedback to care management and leadership team.

• Review and approve initial and ongoing assessments and care plans developed by case managers, care coordinators, and interdisciplinary teams.

• Ensure all care plans are aligned with patient needs, goals, and DHCS requirements, adhering to high clinical standards and ECM program guidelines.

• Oversee compliance with all local, state, and federal regulations, including Medi-Cal ECM program requirements.

• Assist in preparing the program for external regulatory audits conducted by health plans or other governing bodies.

• Provide licensed clinical oversight to ensure that all care coordination and case management services comply with DHCS’s ECM program standards.

• Ensure that documentation and care planning meet DHCS requirements for quality and regulatory compliance, including appropriate care interventions for high-need Medi-Cal beneficiaries.

• Collaborate with ECM leadership to implement continuous quality improvement initiatives based on audit findings.

• Ensure corrective actions are taken when gaps in care coordination or documentation are identified and report these improvements to the ECM leadership team.

• Work closely with interdisciplinary teams, including social workers, case managers, and healthcare providers, to ensure a coordinated, high-quality care approach in line with ECM program goals.

• Communicate audit findings and trends, providing actionable recommendations for process improvements.

• Collect, analyze, and report data from audits to track performance metrics, identify trends, and highlight areas for improvement.

• Generate reports summarizing audit findings and actionable insights, sharing these with ECM leadership for continuous program enhancement.

• Provide regular RN oversight on high acuity cases, which may include assessing high acuity members to identify gaps in care and developing a care plan to address their complex needs.

• Other duties as assigned.

Requirements

Qualifications:

• Current, unrestricted Registered Nurse (RN) license in California.

• Bachelor of Science in Nursing (BSN) or higher degree preferred

• Minimum of 3-5 years of clinical nursing experience, with at least 2 years in case management, care coordination, or auditing roles.

• Prior experience working in Enhanced Care Management (ECM) or managed care programs is highly preferred.

Skills and Abilities:

• In-depth understanding of Medi-Cal ECM program requirements and DHCS

documentation standards.

• Ability to critically analyze clinical documentation and ensure regulatory compliance.

• Strong organizational skills, attention to detail, and ability to communicate findings effectively.

• Excellent verbal and written communication skills for providing feedback to interdisciplinary teams.

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