Health Services Auditor Documentation Specialist
Core
Audits care delivery and documentation of care managers and utilization reviewers to ensure adherence to regulatory guidelines, industry standards, and service agreements.
Role type
Health Services Auditor
Builds
Audit reports and oversight monitoring processes for care management teams
Domain
Health Insurance / Medicare & Medicaid / Utilization Management
Deliverable
dashboards & analysis
Required skills
Clinical Social Work or Registered Nurse licensure, Clinical Documentation, Utilization Management, Care Management, NCQA Standards, CMS Guidelines, Data Analysis, Process Analysis
Preferred skills
Health insurance experience, Government program familiarity (Medicare/Medicaid), Accreditation body knowledge
Technologies
Audit tools, Activity reports, Computer systems
Responsibilities
Audit case file documentation and recorded phone conversations for compliance, Conduct focused audits including pre-delegation and quality assurance reviews, Develop and maintain audit tools to measure efficacy of care managers, Evaluate audit findings and provide recommendations for process improvements, Collaborate with team members to identify policy and procedure changes, Maintain awareness of CMS, State Medicaid, and NCQA requirements