Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Clinical Auditor - REMOTE
🔍 New York, New York
Summary of Position
Manage, monitor and track compliance of the UM, CM, MRU, MCRU adherence to Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, , utilization management, Participate in planning and implementing strategies that provide direction and subsequent monitoring of the UM, CM, MRU, MCRU team functions including assessment of potential new processes and existing processes. Interact with and educate the UM, CM, MRU, MCRU management team, to review Corrective Actions Plans from/for Compliance and ensure that they are being managed and adhered to. Oversee the monthly Key Performance Indicator (KPI), auditing the results and providing feedback to the UM, CM, MRU, MCRU areas on areas that are not meeting Compliance thresholds. Work with Reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards. Work with the Delegates / vendors. Provide services per the NYCE contract.
Principal Accountabilities
- Audit, monitor and track compliance of the UM, CM, MRU, MCRU teams adherence to the Plan, regulatory, and accreditation requirements functions include but are not limited to appeals, case management, utilization management,. This entails reviewing reports against regulatory requirements, looking for trends, notifying management of any trends, and then tracking their responses/actions to ensure the negative trends do not continue.
- Participate in planning and implementing strategies that provide direction and subsequent monitoring of the UM, CM, MRU, MCRU team functions including assessment of potential new processes and existing processes.
- Track UM, CM, MRU, MCRU compliance using the dashboard/matrix, and other organizational and department tools including loading material for organizational use onto SharePoint.
- Oversee and track audit reports and responses, including changes to any policies, procedures and other pertinent information (such as training and attestations) in a central corporate location This includes but is not limited to tracking and maintaining organization of documents including audit schedule, dashboard matrix, and team audit tools, CAPS, completed and incomplete audits, and other functions and processes to ensure efficiency within the Plan.
- Work with Reporting area to develop and maintain reports that provide data from the system and apply it to timeframes/standards.
Uploading reports for Compliance monthly. - Work with the Delegates/vendors and the top 5% report to request/review members that are being submitted for Case Management.
Qualifications
- Associates degree
- Bachelor’s degree preferred. Years of experience can be substituted for years generally required for a degree
- Active, unrestricted Nursing License (RN or LPN) required
- 4-6+ years of experience in a managed care environment including familiarity with auditing, accreditation, compliance, Quality, or delegation or UM experience
- Knowledge of accreditation standards, and regulatory standards such as NYSDOH and CMS
- Experience within an operation that addresses complex relationships and multiple stakeholders with conflicting goals and priorities with diverse needs and skill sets
- Strong problem solving and negotiating skills paired with strong attention to detail
- Knowledge of utilization management process, case management process and, accreditation and regulations as applicable to managed care
- Exercise discretion and maintain confidentiality
- Ability to independently manage multiple tasks or projects simultaneously to successful completion
- Remain highly organized and adhere to processes, policies and procedures
- Excellent interpersonal skills, professionally communicate verbally in person, via telephone, and in writing
- Proficient in understanding and in use of Word, Excel, SharePoint, PowerPoint and Outlook, including excellent working knowledge of MS Office applications
- Highly self-motivated and self-directed independent thinker while being a resource and strong and flexible team player
Security Disclosure
If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.
Pay Disclosure
At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.