Compliance Auditor, Utilization Management at Evolent Health

Remote
Evolent Health

Compliance Auditor, Utilization Management

REMOTE, UNITED STATES

The Compliance Auditor is responsible for working independently on assigned projects and tasks. The Compliance Auditor demonstrates knowledge of Medicare (Parts C), National Committee for Quality Assurance standards and Managed Medicaid regulations and compliance monitoring activities to effectively perform duties that support the company compliance program initiates. The Compliance Auditor is also responsible for conducting routine oversight, monitoring and audits of utilization management services, technical infrastructure, and correspondence within Evolent Health as well as externally delegated functions to ensure compliance with state, federal, and accreditation standards.

Responsibilities:

  • Responsible and accountable to the Director of Utilization Management and Regulatory Compliance.
  • Assist in the facilitation and file preparation of mock audits for the Utilization Management department functions and designated delegates.
  • Assist in the facilitation and file preparation of mock audits for the Utilization Management department functions and designated delegates.
  • Accurately documents audit finding utilizing designated audit tools.
  • Identifies system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations.
  • Provides issue identification, problem analysis and strategies for resolution and/or implementation and communicates to the Director of Utilization Management and Regulatory Compliance and Managing Director of Utilization Management.
  • Assists with development and tracking of corrective action plans to address any identified issues.
  • Conduct annual delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the agreement.
  • Assist with coordination and file preparation of all required external audits e.g. NCQA, CME etc.
  • Assists with development and tracking of corrective action plans to address any identified issues.
  • Participate in workgroups that address both clinical and non-clinical internal activities for which Evolent Health must demonstrate improvement to meet its contractual requirements with the Center for Medicare and Medicaid (CMS), (NCQA) standards, State requirements and any other applicable entity.
  • Serve as knowledge expert for Utilization Management (Prior Authorization and Appeals and Grievances).
  • Participate in the Delegation Oversight Committee meetings, Utilization Management Committee Meetings and other meetings as assigned
  • Act as a liaison with other areas and business units.
  • In collaboration with the Director of Utilization Management and Regulatory Compliance assist with communicating strategic guidance based on regulatory releases for functional utilization management activities as they relate to compliance, regulatory, and government affairs.
  • Monitor and prepare reports on compliance activities and other topics

Qualifications:

Required:

  • RN Clinical with Bachelor’s degree
  • 3+ years’ experience working in a compliance, regulatory, and government affairs functions within a utilization management related medical management arena

Preferred:

  • Knowledge of Utilization Management processes and regulatory requirements for Prior Authorization and Appeals and Grievances.
  • Ability to work in a fast paced, team environment with sensitivity toward client needs and critical deadlines
  • Ability to build trust and form effective relationships with stakeholders.
  • Experience working with a virtual team with variable reporting relationships.
  • Knowledge of clinical operations in managed care, including quality management, outcomes, provider network, claims, utilization management policies, local and national coverage determinations, members’ rights and responsibilities.
  • Establish and maintain effective working relationships with all levels of staff, other business segments, and clients.
  • Experience working with a virtual team with variable reporting relationships

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