Centers Plan for Healthy Living

  • Nurse Auditor

    Job Locations US-NY-Staten Island
    Posted Date 9 months ago(7/20/2018 1:17 PM)
    # of Openings
  • Overview

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    The Nurse Auditor will report to the Chief Compliance Officer and assist with developing, managing and implementing auditing and monitoring activities for the Managed Care Organization (MCO). The Nurse Auditor will provide recommendations along with his/her audit findings in order to mitigate risk and provide viable options to department heads for addressing deficiencies.




    The Compliance Nurse Auditor works with the Compliance Department team to ensure health plan compliance and demonstrates knowledge of: Medicare (Parts C and D); Medicaid Managed Long Term Care as well as integrated and non-integrated Medicaid and Medicare Advantage plan requirements to effectively perform duties that support the company’s compliance program. The Compliance Nurse Auditor will initiate and perform all stages of auditing and monitoring of the various clinical health plan operations to ensure proper compliance with governmental regulations and health plan policies.  Additional responsibilities include, but are not limited to:


    • Reviewing member Universal Assessment Tool (UAS) files, care management notes, care plans, authorizations, medical records, claims and all other relevant documentation related to a members’ case to determine whether documentation substantiates the medical necessity, quality of care, and utilization.
    • Apply knowledge of assessments, care management, regulations, medical coding, common vulnerabilities and process errors, etc. in order to identify areas of non-compliance, potential FWA/Fraud Waste and Abuse issues in provider claims, and opportunities for process improvement and additional training.
    • May assist, as needed, in the root cause analysis required due to audit findings or issue identification and submit recommendations for appropriate mitigation or issue resolution.
    • Provide expertise and assistance relative to CPHL policies and procedures to help ensure they comply with State and/or CMS guidelines/regulations.
    • Document all compliance activities in accordance with department polices and/or workflows
    • Perform other duties and special projects as assigned.



    Education and Experience:





    Bachelor’s degree in Nursing or higher (with active RN license).


    Type of Experience   

    3+ years of experience in Medicare and/or Medicaid Managed Care and Managed Long Term Care


    Specific Technical Skills



    Independent in monitoring and analyzing risk assessments, performing audits, creating reports and scorecards, educating and following up with appropriate departments to ensure processes exist that demonstrate compliance with applicable State and Federal laws, regulations, policies and procedures. Thorough investigation of medical records to determine instances of fraud, waste, and abuse (FWA) within doctors’ charts.

    • Proficient with MS-Office Excel, Visio, PowerPoint, etc.
    • User knowledge of health care related computer systems/applications.




    • Active RN (Registered Nurse) License required


    Knowledge and Skills:

    • Strong analytical, written and verbal communication skills required to ensure service lines and business areas have processes and guidelines in place to comply with applicable State and Federal laws and regulations for Medicare and Medicaid.
    • Knowledge of Medicare (Parts C and D); Medicaid Managed Long Term Care,  as well as integrated and non-integrated Medicaid and Medicare Advantage plans.
    • Thorough understanding of the UAS, Nursing & Social worker assessment and tasking tools, care management and care plans (development, implementation, maintenance and revision) required
    • Four (4) or more years of experience in compliance-related matters in the health care industry.
    • Experience required with drafting policies, procedures and workflows; and developing and implementing corrective action plans.
    • Knowledge of medical coding and payment preferred.
    • Experience in an auditing and/or claims environment helpful. 
    • Must have effective presentation skills and be able to participate in meetings with all levels of management within the organization
    • Must be service oriented, a quick learner, and a team player with the ability to multi-task in a fast-paced environment.
    • Must be detail oriented, have excellent follow-up skills and have an appreciation of cultural diversity and sensitivity to the plan’s target population



    # Direct Reports:        N/A                 


    Physical Requirements:

    The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


    • Must be able to operate office equipment including a computer and phones
    • Able to communicate both in person and by phone
    • Must be able to travel as needed


    The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification.  They should not be construed as an exhaustive list of all responsibilities, duties and skills required.


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