Auditing, Cactus, Corrective Action, Customer Support/Service, Documentation, External Audit, Financial Management, Internal Audit, Leadership, Operational Communications, Policy Development, Procedure Development, Reconciliation, Safety Standards, Team Player
Duties and Responsibilities
Essential Functions:
- Conducts routine and targeted audits of credentialing and enrollment files to verify completeness, documentation, and adherence to established standards.
- Validates primary source verification evidence, required queries, decision documentation, and file timeliness against policy and checklist requirements.
- Audits delegated credentialing-related work products (e.g., roster files and supporting documentation) to ensure accuracy and completeness prior to submission.
- Reconciles provider data across systems (e.g., Cactus, and internal trackers) and identifies discrepancies requiring correction.
- Documents audit findings, assigns issue categories, and communicates results to operational teams and leadership.
- Tracks corrective actions, verifies completion, and performs re-audits as needed to confirm sustained compliance.
- Maintains audit tools (checklists, sampling logs, scorecards) and produces periodic audit reports and trend summaries.
- Partners with credentialing and enrollment staff to provide feedback and support training opportunities based on audit outcomes.
- Supports internal and external audits by compiling documentation and responding to information requests.
Common Expectations:
- Maintains established policies and procedures, objectives, quality assessment and safety standards.
- Maintains professional growth and development.
- Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.