Clinical Audit Manager

Job DescriptionJob Description

POSITION SUMMARY

The Clinical Audit Manager is responsible for ensuring all UM/CM reporting is completed on or before due dates set by our contracted Health Plans. The Clinical Audit Manager is responsible for completing and passing all Health plan audits by due dates set by our contracted Health Plans. The Clinical Audit Manager will work directly with the UM Manager to ensure functions are conducted in a compliant manner. The Clinical Audit Manager is also responsible for confirming all Corrective Action Plans (CAPS) generated from deficiencies found in our reporting, and/or audits by the Health Plan auditors are completed and closed. Communication will be a high priority with the UM Manager and the Director of Clinical Operations of any CAPS received to ensure the deficiency is understood within the working departments, and improvements can be implemented to prevent further deficiencies resulting in further CAPS.

RESPONSIBILITIES-DUTIES

• Prepares and coordinates the completion of complex regulatory and compliance reports for submission.
• Assists in audit preparations, analyzes information, identifies deficiencies, and tracks corrective action for completion. Processes additional data into the system, ensures that data is processed and researches any interruptions to the process.
• Query, analyze, and interpret data for ad hoc analyses.
• Participates in quality assurance process for all new department related system/application/process changes.
• Ability to understand, work with and organize data from various systems and databases: facts, figures, narratives, and data analysis.
• Demonstrate attention to detail and accuracy in work product. Support all levels of claims staff regarding Medicare Commercial, and Medi-Cal, adjudication and coding rules and requirements.
• Locate and download all coding sources for system updating.

• Ensures all reporting instructions (how to generate) are updated and listed in the corresponding P&P
• Assist UM Manager, Director of Clinical Operations to eliminate CAPs and/or operationalize process improvement techniques for better outcomes.
• May assist with automating reports
• Performs as necessary to any departmental changes, workload and/or emergencies
• Understands the UM and CM Departments’ Policies/Procedures
• Ensure templates are accurate per Health Plan including but not limited to new and update information from ICE Website
• Ensures the privacy and security PHI (Protected Health Information) as outlined in AMM policies and procedures relating to HIPPA compliance
• Develop strategies to meet goals
• Set goals and objectives for the team/department
• Performs other duties as directed by Vice President of Operations

EDUCATION AND EXPERIENCE REQUIREMENTS

• 4+ years of experience within an MSO, IPA or Health Plan environment
• Must be highly organized and able to perform multiple tasks efficiently, be computer literate and must be very knowledgeable of all claims processing rules and guidelines
• Must have knowledge of CPT Codes and ICD10 Codes
• Must have Knowledge on all lines of business Medicare, Medi-Cal, and Commercial
• Familiar with regulatory agencies such as CMS, DMHC, DHCS (State of Cal)
• Familiar with required laws pertaining to HIPPA Security & Privacy, Fraud Waste and Abuse
• Knowledge of health plans, medical groups, and managed care operations and related functions and regulations.
• Relevant bachelor’s degree: or equivalent work experience required.
• Ability to work in a fast-paced environment.
• Knowledge of software applications such as EZCAP.

• Must be able to efficiently prioritize multiple high priority tasks.
• Must maintain strict confidentiality of all patient information and IPA business.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!

Join AMM and experience a workplace where your health, growth, and happiness comes first!