Clinical Nurse Educator

The Clinical Auditor is responsible for performing monthly audits for the case management staff to oversee the quality of documentation, adherence to processes, etc. to ensure audit readiness. The Auditor/Trainer is expected to keep monthly reports of audit performance and findings and provide findings to specific employees and leadership in an effort to improve documentation requirements and audit compliance. The Auditor/Trainer will work with each employee to provide feedback and ensure improvement in audit results over time.

The Auditor/Trainer will also complete audits as requested by health plans, HPN and others within the department. The Auditor/Trainer will be an integral part of training and onboarding of new employees. The Auditor/Trainer will provider recommendations of needed ongoing education to provide to the outpatient case management team. The Auditor/Trainer will assist in reviewing Job Aids, templates and other changes proposed within the department to ensure any changes will not negatively impact the department’s audit standards and adherence to required guidelines.

This position will work closely with the Case Managers, Coordinators, Managers, Directors, VPs and Medical Directors to ensure staff are performing to their full potential, as well as continual program development through training and process improvement.

• Graduate from an accredited school for Nursing (LVN or RN)
• Current and maintains California Nursing License.
• Minimum 3-5 years of clinical experience.
• Required one (1) year of Case Management experience but 2-3 years of Case Management experience, preferred.
• Three to five (3-5) years of managed healthcare experience required.
• Computer literate in Word, Excel, and Powerpoint.

Essential Duties and Responsibilities include the following:

• Conducts clinically based concurrent and retrospective reviews of medical records to evaluate the clinical documentation for a reflective quality of care outcome and reimbursement compliance for services provided.
• Conduct monthly reviews of each case manager’s patients to ensure documentation is adhering to health plan requirements and department guidelines. In addition, will ensure that contact of members, completion of care plans, and presentation of patients to IDTs is meeting department and program requirements.
• Maintain accurate records or each monthly review and each audit review.
• Provide findings of reviews in a clear, concise and organized manner to management.
• Provide findings of reviews in a clear, concise and organized manner to each case manager. Will work with case manager to educate and train to ensure improvement of any identified deficiencies.
• Evaluates quality of clinical documentation practices and collaborates with clinical educator and management on remediation plan when indicated.
• Identify, proactively through auditing and internal reporting, negative and positive trends and collaborates with management on recommendations for change.
• Analyze data and conduct root cause analysis on data to determine best plan of correction.
• Assist manager with follow-up on any problems or questions related to the audit results.
• Interfaces with internal department staff telephonically, by e-mail or in person to obtain data.
• Maintains a database for collecting the appropriate data and data-enters information thoroughly and accurately.
• Produces charts, graphs, reports to demonstrate results and outcomes.
• Assists with any corrective actions, as necessary.
• Trains new employees on health plan and department requirements.
• Works with management to create training schedule for case management team so that employees have continuing education.
• Participates in audits conducted by HPN and health plans. This includes reviewing cases prior to meetings to identify potential deficiencies, prepare for audits so that all cases and the required information is easily accessible, participates in meetings as needed with HPN and health plans to go over our audit results.
• Prepares and maintains records and files which are neat, organized, thorough and readily accessed.
• Completes assignments within specified timelines.
• Communicates with internal and external…