Note: The job is a remote job and is open to candidates in USA. Centene Corporation is a diversified, national healthcare organization serving 28 million members through its Medical Management and Health Services team. The Clinical Data Audit Consultant analyzes clinical data, manages audit and regulatory reporting activities, develops workflows and documentation, and recommends process improvements. The role also supports clinical training, staffing analysis, corrective action planning, and cross-functional business requirements.
Responsibilities
- Demonstrates regular, reliable and predictable attendance
- Leads various data analysis projects to examine and define potential clinically related issues and track productivity and quality measures
- Reviews, analyzes, and interprets data for required HEDIS, URAC, NCQA compliance, and related reporting for clinical service teams
- Interprets clinical data that does not conform to established/approved, required specifications, including Unity Reports, and assists in corrective action processes
- Addresses and participates in training of clinical staff resulting from data tracking and analysis efforts
- Identifies, evaluates, recommends and documents clinical business needs and objectives, operational processes and procedures, problems and requirements
- Produces documentation, including project plans, analytical reports, decision backup, information research reports, training plans, business justifications, graphics, workflow and business process models
- Recommends operational and process improvements based on efficiencies and available technologies
- Maintains a repository of performance and audit metrics, and generates management reports illustrating statistical data, text, workflows, and graphics
- Conducts secondary research using a variety of publications, services and health statistic databases
- May also be assigned lower level management functions and back up supervisors on clinical team
- Works with other departments to identify and document business requirements, workflow, policies and procedures
- Organizes and compiles cases for all External Health Net, NCQA, URAC, and Account Audits
- Participates in Quarterly Health Net Regulatory Audit meetings to assist Clinical Directors
- Supports Clinical Supervisors in tracking of monthly Care Manager audit results
- Works with Data Analysis Department to design data pulls
- Assists with generating HLOC and Outpatient Cost of Care and Target Outlier Reports including trend analysis
- Supports staffing analysis with current and forecasted requirements
- Investigates current regulations, interprets findings, and makes recommendations to Healthcare Services teams
- Conducts complex trend analysis and, based on analysis, creates Corrective Action Plans, and presents recommendations to business teams across department to improve performance
- Other duties as required
- Performs other duties as assigned
- Complies with all policies and standards
Skills
- Registered Nurse - Must be Licensed in CA
- Pacific Time Zone Work Hours
- BA/BS in Psychology, Nursing or other related clinical field
- Three to five years case management or related clinical experience
- Two to three years experience conducting business studies, recommending solutions and/or business analysis, preferably in Healthcare
- Licensed Clinician and/or RN required
- Must have and maintain current, valid and unrestricted clinical license
- Masters in Social Work, Counseling, Nursing, or related field preferred
Benefits
- Health insurance
- 401K and stock purchase plans
- Tuition reimbursement
- Paid time off plus holidays
- A flexible approach to work with remote, hybrid, field or office work schedules
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