Job details
Job type full-time
Full job description
It’s time for a change…
Your future evolves here
Evolent health has a bold mission to change the health of the nation by changing the way health care is deliveredOur pursuit of this mission is the driving power that brings us to work each dayWe believe in embracing new ideas, testing ourselves and failing forwardWe respect and celebrate individual talents and team winsWe have fun while working hard and evolenteers often make a difference in everything from scrubs to jeans.
Are we growing? absolutelyWe have seen about 30% average growth over the last three yearsAre we recognized? definitelyWe were named one of “becker’s 150 great places to work in healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important diversity and inclusion (d&i) efforts: evolent achieved a 95% score on its first-ever submission to the human rights campaign`s corporate equality index; was named on the best companies for women to advance list 2020 by parity.org; and we publish an annual diversity and inclusion annual report to share our progress on how we’re building an equitable workplaceWe recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each dayIf you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a missionJoin a mission with a company behind it.
The quality auditor role is responsible for working independently on assigned projects and tasksThe compliance auditor demonstrates knowledge of medicare (parts c), national committee for quality assurance standards and managed medicaid regulations and compliance monitoring activities to effectively perform duties that support the company compliance program initiatesThe compliance auditor is also responsible for conducting routine oversight, monitoring and audits of utilization management services, technical infrastructure, and correspondence within evolent health as well as externally delegated functions to ensure compliance with state, federal, and accreditation standards.
Responsibilities:
Responsible and accountable to the director of utilization management and regulatory compliance.
Assist in the facilitation and file preparation of mock audits for the utilization management department functions and designated delegates.
Accurately documents audit finding utilizing designated audit tools.
Identifies system and/or operational issues hindering the attainment of quality performance standards as defined by ncqa standards, applicable state and federal laws and regulations.
Provides issue identification, problem analysis and strategies for resolution and/or implementation and communicates to the director of utilization management and regulatory compliance and managing director of utilization management.
Assists with development and tracking of corrective action plans to address any identified issues.
Conduct annual delegation audits for applicable areas for existing delegated entities and ensure that vendors continue to perform the delegated activities in accordance with the agreement.
Assist with coordination and file preparation of all required external audits e.gNcqa, cme etc.
Assists with development and tracking of corrective action plans to address any identified issues.
Participate in workgroups that address both clinical and non-clinical internal activities for which evolent health must demonstrate improvement to meet its contractual requirements with the center for medicare and medicaid (cms), (ncqa) standards, state requirements and any other applicable entity.
Serve as knowledge expert for utilization management (prior authorization and appeals and grievances).
Participate in the delegation oversight committee meetings, utilization management committee meetings and other meetings as assigned
Act as a liaison with other areas and business units.
In collaboration with the director of utilization management and regulatory compliance assist with communicating strategic guidance based on regulatory releases for functional utilization management activities as they relate to compliance, regulatory, and government affairs.
Monitor and prepare reports on compliance activities and other topics
Qualifications:
Required:
Rn clinical with bachelor’s degree (may consider rn, lpn with associates degree based on level of experience)
Experience working with compliance and regulatory functions within a utilization management related medical management arena
Preferred:
Knowledge of utilization management processes and regulatory requirements for prior authorization and appeals and grievances.
Ability to work in a fast paced, team environment with sensitivity toward client needs and critical deadlines
Ability to build trust and form effective relationships with stakeholders.
Experience working with a virtual team with variable reporting relationships.
Knowledge of clinical operations in managed care, including quality management, outcomes, provider network, claims, utilization management policies, local and national coverage determinations, members’ rights and responsibilities.
Establish and maintain effective working relationships with all levels of staff, other business segments, and clients.
