Grievance and Appeals Internal Auditor

Overview:

The Internal Auditor is an important position to ensure quality case investigations within the Grievance & Appeals Department (G&A). The auditor assesses the quality of all grievance and appeal cases to ensure they meet DHCS-mandated requirements, NCQA specifications, and Partnership professional standards.  Conducts individual audits of grievance, appeal, exempts, and State Hearing cases completed by the Grievance staff. Identifies and recommends improvements to advance the overall quality of investigation outcomes.

Responsibilities:

• Regularly conducts concurrent and retrospective audits of individual case investigations according to established audit criteria and provides feedback to associates as applicable
• Performs routine and timely quality assurance audits for all types of cases – grievance, appeals, exempts, and State Hearing cases conducted on a standard or expedited basis
• Assesses cases to determine if DHCS-mandated timeframes, NCQA specifications, and Partnership professional standards for member experience are met
• Determines if clinical guidance is executed accurately throughout the case investigation process
• Evaluates the quality of written communications
• Assesses accurate use of reporting fields to support DHCS, NCQA, and interdepartmental reporting interests
• Evaluates the appropriateness of referrals and determine if best resolution is offered given nature of case
• Enters audit findings of individual cases in the audit tracking database
• Provides audit findings feedback to G&A Manager and Supervisors regarding associates’ audit performance.
• Keeps current on all regulatory requirements that may influence G&A audit criteria and/or practices
• Recommends areas in need of additional training and/or close oversight based on the trending and analysis of audit results
• Makes strategic recommendation(s) to improve the accuracy, quality, and/or reporting of case investigations based on audit observations in order to enhance members’ healthcare experience
• Assists in the development and maintenance of auditing guidelines, including the audit tracking database
• To support regulatory compliance, creates and maintains desktop(s) to document policy and procedures for G&A audit practices
• Maintains strict confidentiality of members’ PHI/PII

 

SECONDARY DUTIES AND RESPONSIBILITIES

• May participate in special projects or initiatives as directed

Qualifications:

Education and Experience

Bachelor’s degree in a health or business related field preferred; two (2) years of experience with grievance, appeal, and State Hearing cases or equivalent combination of education and experience.  Experience with medical criteria used to determine approval of medications, services, or referrals desired (e.g., TAR, RAF). Very detailed oriented, excellent writing and communication skills. General knowledge of managed care and Medi-Cal benefits desired

 

Special Skills, Licenses andCertifications

Experience in managed care business practices and the ability to access data information using computer systems. Ability to work within an interdisciplinary structure and function independently in a fast-paced environment while managing multiple priorities and meeting deadlines. Strong organizational skills required. Effective telephone, computer and,  data entry skills required. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

 

Performance Based Competencies

Excellent written and verbal communication skills with ability to read and interpret benefit contract specifications are required. Ability to understand and ensure compliance with established criteria and protocols used in managed care functions. Ability to formulate ideas and solutions into appropriate questions and assess/interpret the verbal responses. Ability to communicate effectively with coworkers, members, their families, physicians, and health care providers. Self-driven and works independently

 

Work Environment And Physical Demands

Heavy use of the computer for most of the day. Must be able to lift, move, or carry objects of varying size, weighing up to 10 lbs.

 

 

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

 

$42.38 - $52.97

 

IMPORTANT DISCLAIMER NOTICE

 

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.