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:
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.
Knowledge and Skills:
# Direct Reports: N/A
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.
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.