Clinical Quality Auditor, Consultant

Your Role

The Quality Review team completes audits of front-line staff to ensure alignment with department processes and regulatory compliance. Clinical Quality Auditors also provide coaching and work closely with business leaders to drive optimal results. The Clinical Quality Auditor, Consultant will report to the Quality Review Senior Manager. In this role you will develop performance metrics, evaluate performance, and provide coaching to ensure that staff have the skills and knowledge required to be successful in Population Health Management and Utilization Management.

Your Work

In this role, you will:

• Perform audits for Population Health Management (PHM) and Care Coordination adhering to monthly productivity and quality metrics
• Review audit data to identify care gaps, compliance risks, and trends
• Communicate findings to leadership and provide recommendations to mitigate risks
• Design, implement, evaluate and improve audit criteria and coaching strategies to meet the needs of PHM clinical staff
• Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work
• Conduct effective presentations relating to PHM processes and/or regulatory compliance for clinical staff
• May independently represent the Quality Review department in PHM and work re-design, process changes and software implementation
• Act as a resource for the training and auditing team 

Your Knowledge and Experience

• Requires a Bachelor’s of Science in Nursing or advanced degree preferred

• Current California RN license required

• At least 7 years of experience in managed care or similar complex healthcare environment with a minimum of 1 year experience in Case Management required
• Auditing experience preferred
• Population Health Management and Utilization Management experience preferred
• Strong organizational and/or project management skills to coordinate departmental projects and to perform multiple projects or tasks simultaneously
• Subject matter expert with capability to effectively audit and train all lines of business (Commercial, Federal Employee Program, Medicare, and Medi-Cal)