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makes it easier to access care and to age safely at home.
This is your opportunity to join an innovative company with a culture that promotes compassion, trust and accountability.
ABOUT THIS OPPORTUNITY
The Level I position is responsible for claims quality audits for all Univita clients; ensuring that claims staff abides by approved Best Practice Standards utilizing any client specific practices; training the claims and care management staff; and investigating potential fraud on behalf of designated clients.
The Level II position is responsible in providing backup to the Medical Director regarding case consults, assisting the Director in development and revision of the practice standards, interacting with clients regarding audit results as well as assuming the lead in special projects related to claims and auditing under direction of the Director.
Title: Clinical Auditor and Investigator, Claims (Level I)
1. Provides quality assurance reviews for care managers and care coordinators for all clients to ensure appropriate benefit determination decisions are made, appropriate benefit periods are established and appropriate care plans are written providing feedback to the individual in writing or verbally.
2. Conducts audits through review, interpretation and application of plan language and approved protocols.
3. Develops and revises training materials, schedules and conducts the training for new and existing Care Management, Care Coordinators and Claims staff, ensuring they are compliant with internal, client and Univita specific Practice Standards.
4. Participates in case consultations for the claims and care management teams.
5. Interacts directly with client management on issues related to appeals, new client or product implementation and proposed/revised practice changes.
6. Communicates effectively in writing and verbally with internal and external customers.
7. Completes a monthly and quarterly report summarizing the activities and audit results for the reporting period, distributing the results to management.
8. Under the direction of the Vice President of Clinical Services, conducts investigations of potentially fraudulent claims, coordinates vendor services, summarizes findings and makes recommendations to the client. Participates in discussions with the clients to present the investigation information.
Non essential duties:
1. Provides assistance with policy interpretation as needed.
2. Participates in monthly audit rebuttal meetings to discuss audit findings with operations management staff, as well as care managers and care coordinators.
3. Under direction of the Director of Clinical Quality and Standards or VP of Clinical Services, identifies and develops new, as well as revises, current Claims and Care Management procedures and policies for new and existing clients or vendors.
4. Participates in discussions and provides recommendations to operations management for improving process and efficiency, as requested.
5. Assists the Director or Vice President of Clinical Services with external client audits for claims and care management at client locations.
6. Other duties as assigned.
Title: Senior Clinical Auditor and Investigator, Claims (Level II)
Above requirements and the following:
1. Leads the other team members in the completion of monthly audits timely, monitoring the required volume of audits for all clients to meet the required deadlines.
2. Schedules and facilitates internal operational and team meetings, including creating a written agenda.
3. Facilitates the writing and revision of Practice Standards for the Claims Operations team, involving them in the review process prior to finalization.
4. Provides technical assistance for letter writing and other written documentation.
5. In the absence of the Director or Vice President of Clinical Services, is authorized to make a decision regarding final responses on audit rebuttals.
6. Participates in discussions and provides recommendations to operations management for improving process and efficiency.
7. Schedules and facilitates all new hire and on-going training, providing direction to the team on scheduling.
8. Supports operations management as the clinical subject matter expert for implementation of new clients to ensure the new client procedures and clinical protocols are compliant with client policy and plan documents, intent and with approved Best Practice standards.
9. Contacts and works with outside vendors for questions and problems regarding potential fraud investigations.
10. Participates in special projects such as ICD-10, data analytics, etc.
11. Provides back up for the Director in her/his absence.
• RN, LSW, LGSW with valid and unrestricted license
• Minimum of 2 years Long Term Care Claims experience
• Communicates effectively in writing and verbally
• Required to uphold the principles of compliance as outlined in the Code of Conduct, Employee Handbook and related policies and procedures. Supports and participates in the mandatory Corporate Compliance Program training initiative on an annual or more frequent basis, as required.
• All of the above plus:
• Minimum of 2 years of Clinical Auditor and Investigator, Claims experience
• Communicates effectively and with confidence in a group setting and is able to facilitate meetings including writing the agenda if necessary.
• Certified Care Manager
• Knowledge of health, long-term care or disability insurance required.
• At least three years clinical experience working with a geriatric population, ideally in a long term care or nursing home facility, home care, public health or hospice environment.
• Experience in care management; including care plan development and maintenance, care coordination and ability to interpret insurance policy language preferred.
• Previous Clinical Quality or claims audit experience preferred.
• Good communication and writing skills
Certifications required: None
Continuing education requirements: As required to maintain current licensure