Clinical Audit Manager - MSO IPO HP

Job Description

Position Summary

The Clinical Audit Manager plays a key role in ensuring timely and accurate completion of Utilization Management (UM) and Case Management (CM) reports in accordance with deadlines set by contracted Health Plans. This position is responsible for successfully managing and passing Health Plan audits, and for collaborating closely with the UM Manager to maintain compliance across all functions.

A critical aspect of this role involves overseeing the resolution of Corrective Action Plans (CAPs) resulting from audit findings or reporting deficiencies. The Clinical Audit Manager will communicate effectively with the UM Manager and Director of Clinical Operations to ensure CAPs are clearly understood and addressed within relevant departments, driving process improvements to prevent recurrence.

Key Responsibilities

Prepare and coordinate complex regulatory and compliance reports for timely submission.

Support audit readiness by analyzing data, identifying gaps, and tracking corrective actions to closure.

Investigate and resolve data processing issues; ensure data integrity across systems.

Conduct ad hoc data analysis and reporting using various databases and tools.

Participate in quality assurance for new systems, applications, and process changes.

Interpret and organize data from multiple sources for reporting and analysis.

Ensure accuracy and attention to detail in all deliverables.

Provide guidance to claims staff on Medicare, Medi-Cal, and Commercial coding and adjudication rules.

Maintain and update coding sources and system references.

Document and update reporting procedures in relevant policies and procedures.

Collaborate with leadership to eliminate CAPs and implement process improvements.

Assist in report automation initiatives where applicable.

Adapt to departmental changes, shifting workloads, and urgent priorities.

Maintain a thorough understanding of UM and CM departmental policies and procedures.

Ensure Health Plan templates are current, including updates from the ICE website.

Safeguard Protected Health Information (PHI) in accordance with company HIPAA policies.

Develop and execute strategies to meet departmental goals and objectives.

Perform additional duties as assigned by the Vice President of Operations.

Qualifications

Minimum 4 years of experience in a Managed Services Organization (MSO), Independent Physician Association (IPA), or Health Plan setting.

Strong organizational skills with the ability to manage multiple priorities efficiently.

Proficient in claims processing rules and guidelines.

In-depth knowledge of CPT and ICD-10 coding.

Familiarity with Medicare, Medi-Cal, and Commercial lines of business.

Understanding of regulatory bodies such as CMS, DMHC, and DHCS.

Knowledge of HIPAA regulations, including privacy, security, and fraud prevention.

Experience with managed care operations and compliance requirements.

Bachelor's degree or equivalent work experience required.

Ability to thrive in a fast-paced environment.

Proficiency in EZCAP or similar healthcare software.

Commitment to maintaining confidentiality of patient and company information.

EXCELLENT COMPANY BENEFITS INCLUDING 100% Paid Medical HMO - with optional coverages available as well

Various Reimbursements and Work-Life Balance incentives

Desired Skills and Experience

The Clinical Audit Manager plays a key role in ensuring timely and accurate completion of Utilization Management (UM) and Case Management (CM) reports in accordance with deadlines set by contracted Health Plans. This position is responsible for successfully managing and passing Health Plan audits, and for collaborating closely with the UM Manager to maintain compliance across all functions.

A critical aspect of this role involves overseeing the resolution of Corrective Action Plans (CAPs) resulting from audit findings or reporting deficiencies. The Clinical Audit Manager will communicate effectively with the UM Manager and Director of Clinical Operations to ensure CAPs are clearly understood and addressed within relevant departments, driving process improvements to prevent recurrence.

All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. For unincorporated Los Angeles county, to the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.