The Compliance Nurse Auditor will audit, monitor, review and analyze changes to laws and regulations and investigate fraud, waste and abuse to ensure compliance with State & Federal mandates. The Compliance Nurse Auditor is responsible for auditing clinical reviews for medical necessity, quality and related reviews using Trusted policies and procedures. The Nurse Auditor is required to use medical management guidelines to determine whether services are properly authorized, including whether services are appropriate and justified. Identifies and refers potential issues to the Chief Compliance Officer when guidelines are not met.
ESSENTIAL DUTIES AND RESPONSIBILITIESOversee contract compliance activities and vendor oversight by using audit and investigation tools.Develop methods for reviewing data to identify fraud, waste and abuse in various claim systems.Knowledge and experience in information privacy laws, access, release of information and release of control technologies.Manages the delivery of initial and privacy trainings and orientation to all employees, volunteers, medical and professional staff, contractors, alliances, business associates, and other appropriate third parties.Manages a mechanism to track and audit access to protected health information.Initiates, facilitates and promotes activities to foster information privacy awareness within the organization and related entities.Applies clinical authorization and review processes (InterQual Medical Guidelines, process standards, policies and procedures, and standard operating procedures) to submitted information. Where needed, audits medical records in accordance with medical and health guidelines.Participates in investigations and compliance team meetings with other internal and external partners to collaborate on the detection and resolution of fraud and abuse.Works with all organization personnel involved with any aspect of release of protected health information, to ensure full coordination and cooperation under the organization s policies and procedures and legal requirementsMaintains current knowledge of applicable federal and state privacy laws and accreditation standards, and monitors advancements in information privacy technologies to ensure organizational adaptation and compliance.Assists promptly with the investigation of key personnel failing to perform their responsibilities as reported by State or Federal regulators.Reviews data files and audits health records and other documentation as part of investigations.Takes any actions the company reasonably determines necessary to ensure full compliance with the terms of the company's contract with State entities.With the direction of the Chief Compliance Officer, will notify State or Federal agencies of any investigation conducted or actions taken on non-compliant providers.Manage any applicable Corrective Action provisions invoked by State or Federal regulators if the company fails to ensure full compliance.When conducting post-service reviews and audits, documents audit activities for reviews and completes details as needed. Ensures audit files are timely, complete and accurate.When conducting reviews for Utilization or Care Management, documents audit activities and completes details as needed. Ensures audit files are timely, complete and accurate.Must have very strong writing skills, be detail-oriented, and be able to work independently on multiple tasks/projects in coordination with other internal and external project team members.Performs other duties as assigned.
QUALIFICATIONS2+ years of experience and knowledge within the Medicaid/managed care setting.2+ years of experience and knowledge working with claims health data.Comprehends complex clinical data. Possesses computer and management reporting and analysis skills.Able to organize, prioritize and manage time effectively.Ability to learn quickly and has a flexible work schedule.Knowledge of NCQA HEDIS abstracting guidelines.Requires effective interpersonal communication skills, both written and verbal, and has the discretion to manage confidential patient information from medical records and other internal and external sources.Managed care experience required with a focus on Medicaid population preferred.Knowledge of CPT, ICD9-CM, HCPCS or other coding structures.
Bachelor s degree in Nursing.
Current Unrestricted RN License in DC.