Remote Clinical Programs Auditor RN, FL

Florida Blue

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United States Clinical Full-Time 32715

What is your impact:
The Clinical Auditor is to evaluate the operational effectiveness of clinical decision making, business processes, management, and related internal controls. Additional key functions include identifying process deficiencies and gaps which directly impact internal departmental efficiencies as well as regulatory and accreditation requirements (CMS, NCQA). Requires general clinical, system, and business process knowledge related Utilization Management, Case Management, Billing and Coding, and Claims areas. Will be responsible for interacting directly with internal and external Management within the various business areas.

What are your key responsibilities:
Design and administer audit programs which meets the clients’ business needs (Utilization Management, Case Management, Disease Management, Payment integrity Office, and other business areas)
Evaluating the Health of the business through assessments over the effectiveness of business processes and controls to include the following:
• Identification of risks and control/process gaps through root cause analysis within the current business processes
• Oversight of the Clinical Audit process improvement and corrective action plans
• Monitoring and identification of trends through data analysis which drive process efficiencies and improve compliance adherence
• Collaborate with Medical Directors, Managers, Sr. Managers, Peers, and internal staff

What is required?
2+ years related work experience defined as clinical experience in a hospital setting
RN – Registered Nurse – State Licensure And/Or Compact State Licensure Current Florida RN license
Experience in one or more of the following: home health care, rehab, utilization review, discharge planning or case management
Experience with the health insurance industry (Managed Care)
Experience with Utilization Review
Experienced in MS Word and Excel Occasional travel within the State of Florida
Previous experience/knowledge with National Committee Quality Assurance (NCQA) Utilization Management Accreditation or other NCQA Accreditation
Advanced technical expertise (i.e., data dashboards, Nintex forms)
Experience with continuous improvement projects

What is preferred?
Experience in Disease Management/Case Management preferred Experience/knowledgeable of internal documentation applications, i.e. Jiva, Diamond
Experience developing and/or conducting documentation audits for Clinical/Quality
Bilingual English/Spanish

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:
•  Medical, dental, vision, life and global travel health insurance;
•  Income protection benefits: life insurance, Short- and long-term disability programs;
•  Leave programs to support personal circumstances;
•  Retirement Savings Plan includes employer contribution and employer match;
•  Paid time off, volunteer time off, and 11 holidays
•  Additional voluntary benefits available; and
•  A comprehensive wellness program
Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Annualized Salary Range: $66,400 – $107,900
Typical Annualized Hiring Range: $66,400 – $83,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.