What are the responsibilities and job description for the Medical Management Auditor position at Sunshine State Health Plan?
Transforming the health of our communities, one person at a time, is a monumental task that requires dedication and expertise. As a key member of our Behavioral Health Team in Florida, you will play a pivotal role in shaping the future of healthcare.
Position Purpose:
The primary responsibility of this position is to oversee the auditing process for corporate, health plan, and specialty company staff related to clinical systems entry and/or processes.
- Audit Process Development: Develop and maintain the audit process and tools related to authorizations, appeals, quality events, and case management in CCMS; interrater reliability related to InterQual; and data entry into the credentialing subsystem.
- Schedule Management: Develop and maintain the audit schedule.
- Staff Auditing: Audit staff as outlined in the system auditing policies.
- Training and Facilitation: Train audit staff at the health plan in the use of audit process and tools and facilitate compliance with the auditing process.
- Consulting: Act as a consultant related to system auditing to others in the unit, department, and health plan.
- Problem Resolution: Work with staff to identify and resolve authorization load error report system problems.
- Corrective Action: Coordinate auditing outcomes with the Trainer to identify, develop, and publish corrective actions/educational material related to audit errors.
- System Enhancement: Coordinate auditing outcomes and system maintenance with the Sr. Clinical Systems Specialist to resolve or enhance clinical systems.
- Travel Requirement: Ability to travel.
- Additional Responsibilities: Performs other duties as assigned and complies with all policies and standards.
Education/Experience:
To be successful in this role, you will require a Bachelor's degree in a related field or equivalent experience, along with 3 years of related experience.
License/Certification:
You must hold a State unrestricted license as a Licensed Master Social Worker (LMSW), Licensed Clinical Social Worker (LCSW), Licensed Mental Health Counselor (LMHC), Registered Nurse (RN), or Licensed Psychologist (Ph.D. or Psy.D.).
What We Offer:
Centene offers a comprehensive benefits package, including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field, or office work schedules.
Equal Opportunity Employer:
Centene is an equal opportunity employer committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Application Consideration:
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
