Maintain confidentiality in compliance with all Health Insurance Portability and Accountability Act (HIPAA) requirements. Assists co-workers with special projects or work volume as required. Actively identifies and implements efforts to improve the quality, effectiveness and efficiency of job functions. Actively identifies and makes recommendations to supervisor ideas to improve the quality effectiveness and efficiency of departmental and health services functions. Communicates to supervisors any barriers to completing assignments or daily work in an efficient and effective manner.
Provide training, education and consultation as necessary to PP and PPGs. Collaborate with other Clinical Auditors on identifying topics and developing agendas for the JOM's and PP visits/communication. Develop and implement procedures to assure compliance with care coordination and documentation of linked and carved out services.
Conducts Interrater Reliability Testing (referral management and oversight) for new staff/physicians and annually or as needed for existing staff/[physicians.
Works with other departments as necessary to facilitate teamwork for creating and/or improving interdepartmental processes to meet regulatory requirements.
Clinical Auditor (Performance Monitoring): In addition to the responsibilities above, the Clinical Auditor (Performance Monitoring) position ensures compliance of the delegates (Participating Physician Groups, Plan Partners and Vendors) with regulatory, contractual and L.A. Care business requirements. This position is responsible for delegation oversight continuous monitoring activities and monitoring corrective action plans from the annual and focused audits. The position also acts as a liaison between the Plan Partners, PPGs and Vendors regarding Utilization Management (UM) issues; assists in improving access and utilization performance of PPGs by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility of this position includes attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards.
Clinical Auditor (Behavioral Health): In addition to the duties above, the Clinical Auditor (Behavioral Health) will design an audit program specific to ensuring delegates are meeting behavioral health regulatory requirements. This will ensure Specialty Health Plans and Plan Partners are in compliance with regulatory, contractual, and L.A. Care business requirements. This Position is responsible for developing and maintaining annual audit tools, policy requirements specific to delegates, and a monitoring program to continually receive and aggregate Behavioral Health specific performance requirements. The position will act as a liaison between Specialty Health Plans and Plan Partners regarding Behavioral Health issues, assists in improving access and Behavioral Health performance by being a resource for best practice and providing continuous performance feedback. Additionally, the oversight responsibility includes liasing with internal Behavioral Health units, the Medical Director of Behavioral Health, attendance at UM Committee, Delegation Oversight Committee, Sanctions Committee, Internal Compliance Committee, and Joint Operation Meetings. It includes monitoring supplemental UM reports, reporting to management as well as consultation/coaching/instructional activities to improve overall compliance with all regulations and standards.
Performs other duties as assigned.
