Clinical Operations Auditor

Now hiring a Clinical Operations Auditor

Performs daily operational activities in the PHP Clinical Operations Department including, but not limited to, overseeing audit compliance activities for Case Management, Care Coordination, and Utilization Management to ensure regulatory requirements are met; preparing all internal and external audits for all lines of business; completing all audit projects requiring the computation, analysis, and formatting of reports and providing individual and group education on audit findings

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Ideal Candidate:

Bachelors degree in Social Work, Nursing, or Healthcare-related field. Active, unrestricted State Registered Nursing license or Licensed Independent Social Worker (LISW) or Advanced Practice Social Worker (APSW) in good standing.

• Bachelors degree in Social Work, Nursing, or Healthcare-related field or applicable experience in lieu of degree and 6 years relevant work experience required.
• Active, unrestricted State Registered Nursing license or Licensed Independent Social Worker (LISW) or Advanced Practice Social Worker (APSW) in good standing highly preferred.
• Experience in utilization management, quality assurance, home care, community health, long term care or occupational health required.
• Proficiency in Microsoft Word, Excel and Outlook required. Experience in analyzing trends based on decision support systems.
• Business management skills to include, but not limited to, cost/benefit analysis, negotiation, and cost containment

• Manages, conducts and maintains compliance activities to ensure they meet and satisfy regulatory requirements for NCQA, Peer Review Organizations; CMS, DOI, and other monitoring entities. Completes reports as required.
• Monitors/reviews/audits Clinical Operations records for all product lines to ensure accuracy and appropriateness of utilization management functions and ongoing compliance to policies, procedures, and guidelines related to regulatory requirements. Implements change initiatives to enhance compliance efforts. Serves as a resource and educates staff.
• Develops and implements tools to measure compliance with established standards. Reviews and revises tools as standards change. Tracks and trends result. Identifies and implements opportunities for improvement.
• Coordinates and works closely with managers and other departments on all audits and audit-related projects to support and ensure consistency of practice and decision making.
• Manages preparation for accreditation and regulatory audits as assigned to include the interpretation of standards and development of mechanisms for compliance. Manages activities and prepares files and documents to support accreditation and regulatory audits for all product lines.
• Develops standards of performance, evaluates performance, and initiates or makes recommendations for personnel actions. Coordinates and acts as a resource for policies, procedures, and operational changes related to utilization review, denials, and timeliness standards.
• Promotes system-wide strategies and compliance with policies and standards, adopted accreditation standards and federal/state health insurance regulatory requirements.
• Mentors staff on Case Management / Care Coordination Assessment, Care planning, Service Coordination, Utilization Management, and decision-making skills.
• Performs other functions as required

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.