Position Purpose: Lead, monitor and evaluate the performance of national delegated vendors according to CMS, NCQA, Federal and State requirements.
- Lead compliance audits of vendors. Identify audit scope and requiredaudit tools. Ensure audit results are appropriated compiled and accounted for within designated audit tools
- Manage, audit, and monitor both internal and external vendors against CMS, contractual, Federal, State, and NCQA standards
- Review vendors documented processes against contractual, Federal, State, CMS, and NCQA standards
- Identify process gaps and deficiencies and communicate audit observations, recommendations, and process improvement opportunities
- Develop and implement quality improvement and corrective action plans based on risk analysis, audit findings, and vendor performance
- Develop audit tools based on contracted services with vendors and requirements defined by CMS, State, Federal, Medicaid and/or NCQA guidelines
- Maintain documentation on vendor performance and provide reports to subsidiaries as required for audits and risk assessments. Lead vendor performance oversight meetings with impacted business owners and vendors
- Utilize clinical knowledge to determine audit findings and in answering counterclaims
- Train internal audit participants/business owners on audit tools and Medical Management criteria including CM, DM, and UM
- 80% travelrequired
Education/Experience: Bachelor’s degree in a clinical field or equivalent experience. 4+ years of combined clinical and compliance or auditing experience in a healthcare environment. Familiarity with Health Insurance Marketplace, Medicaid and Medicare managed care practices and policies preferred.