Clinical Data Audit Consultant

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🔥 0 minutes ago

🌵 Arizona, California, +3 more states – Remote

🌵 Arizona – Remote 🏄 California – Remote 🥔 Idaho – Remote 🌶️ New Mexico – Remote ⛷️ Utah – Remote

💵 $33 - $60 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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Centene Corporation

WebsiteLinkedInAll Job Openings

10,000+ employees

Founded 1984

🛡️ Insurance

💼 Consulting

🏥 Healthcare

Insurance • Consulting • Healthcare

Centene Corporation is a leading provider of government-sponsored healthcare services, specializing in delivering affordable and high-quality healthcare solutions. For over 40 years, Centene has focused on transforming the health of communities by expanding access to Medicaid, Medicare, and Health Insurance Marketplace services, as well as serving military communities through the TRICARE program. As the largest Medicaid managed care organization and a key participant in the Marketplace, Centene emphasizes localized healthcare delivery combined with strong partnerships with nonprofit organizations to meet the unique needs of its members. Centene is also committed to corporate sustainability and social responsibility, prioritizing environmental stewardship and ethical governance to enhance the well-being of the communities it serves.

📋 Description

• Lead data analysis projects to identify clinically related issues and track productivity and quality measures • Review, analyze, and interpret data for HEDIS, URAC, NCQA compliance, and related reporting • Interpret nonconforming clinical data and assist with corrective action processes • Address and participate in clinical staff training resulting from data tracking and analysis • Identify, evaluate, recommend, and document clinical business needs, objectives, processes, procedures, problems, and requirements • Produce project plans, analytical reports, decision backup, research reports, training plans, business justifications, graphics, workflows, and business process models • Recommend operational and process improvements based on efficiencies and available technologies • Maintain performance and audit metrics repositories and generate management reports • Conduct secondary research using publications, services, and health statistic databases • Perform lower-level management functions and back up clinical team supervisors as assigned • Collaborate with departments to document business requirements, workflows, policies, and procedures • Organize and compile cases for External Health Net, NCQA, URAC, and Account Audits • Participate in Quarterly Health Net Regulatory Audit meetings • Support Clinical Supervisors in tracking monthly Care Manager audit results • Work with Data Analysis to design data pulls • Assist with HLOC, Outpatient Cost of Care, and Target Outlier Reports, including trend analysis • Support staffing analysis using current and forecasted requirements • Investigate regulations, interpret findings, and make recommendations to Healthcare Services teams • Conduct complex trend analysis, create Corrective Action Plans, and present recommendations to business teams • Perform other assigned duties and comply with policies and standards

🎯 Requirements

• Registered Nurse; must be licensed in California • Must have and maintain a current, valid, and unrestricted clinical license • Licensed Clinician and/or RN required • BA/BS in Psychology, Nursing, or another related clinical field required • Master’s in Social Work, Counseling, Nursing, or a related field preferred • Three to five years of case management or related clinical experience • Two to three years of experience conducting business studies, recommending solutions, and/or business analysis, preferably in healthcare • Pacific Time Zone work hours • Demonstrates regular, reliable, and predictable attendance • Must comply with all policies and standards

🏖️ Benefits

• Competitive pay • Health insurance • 401K plans • Stock purchase plans • Tuition reimbursement • Paid time off plus holidays • Flexible approach to work with remote, hybrid, field or office work schedules • Additional forms of incentives may be included in total compensation