Clinical Data Audit Consultant

This is a fully remote position, open to applicants in Arizona, +4 more states.

📋 Description

• Lead data analysis initiatives to identify clinically relevant issues while monitoring productivity and quality metrics.

• Review, assess, and interpret data to ensure compliance with HEDIS, URAC, NCQA, and related reporting standards.

• Analyze nonconforming clinical data and support corrective action initiatives.

• Engage in clinical staff training as a result of data tracking and analysis efforts.

• Identify, assess, recommend, and document clinical business needs, goals, processes, procedures, challenges, and requirements.

• Develop project plans, analytical reports, decision support documents, research reports, training materials, business justifications, visual graphics, workflows, and business process models.

• Suggest operational and procedural enhancements based on efficiencies and available technologies.

• Maintain repositories for performance and audit metrics while generating management reports.

• Conduct secondary research utilizing publications, services, and health statistics databases.

• Perform lower-tier management duties and provide support for clinical team supervisors as needed.

• Collaborate with various 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.

• Assist Clinical Supervisors in monitoring monthly Care Manager audit results.

• Collaborate with Data Analysis teams to design data extraction processes.

• Provide assistance with HLOC, Outpatient Cost of Care, and Target Outlier Reports, including performing trend analysis.

• Support staffing analysis based on current and anticipated requirements.

• Investigate regulations, interpret outcomes, and provide recommendations to Healthcare Services teams.

• Conduct complex trend analyses, develop Corrective Action Plans, and present proposals to business teams.

• Execute other assigned tasks and adhere to all policies and standards.

⛳️ Requirements

• Must be a Registered Nurse; a California license is required.

• Must possess and maintain a current, valid, and unrestricted clinical license.

• Licensed Clinician and/or RN is mandatory.

• A BA/BS in Psychology, Nursing, or another relevant clinical field is required.

• A Master’s degree in Social Work, Counseling, Nursing, or a related field is preferred.

• Three to five years of experience in case management or a related clinical field is necessary.

• Two to three years of experience in conducting business studies, recommending solutions, and/or business analysis, ideally in a healthcare setting.

• Must work during Pacific Time Zone hours.

• Demonstrates consistent, reliable, and predictable attendance.

• Must adhere to all policies and standards.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plans.

• Stock purchase plans.

• Tuition reimbursement opportunities.

• Paid time off in addition to holidays.

• Flexible work options, including remote, hybrid, field, or office schedules.

• Additional forms of incentives may also be included in total compensation.