Operations Quality Auditor, Utilization Management

Amerihealth
Published
October 2, 2020
Location
Philadelphia, PA
Category
Job Type

Description

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

Under the direct supervision of the Supervisor, Manager and/or Director of Operations Quality Auditing, the Utilization Management Auditor is responsible for completing independent, objective internal compliance audits designed to test and confirm compliance with applicable State and Federal guidelines, reporting to the Manager of Quality Auditing.

  • Performs review of Utilization Management cases including all written communication to ensure all contractual requirements have been met and all internal operation processes were followed to ensure correct completion of UM case.
  • The auditor will also serve as a subject matter expert within the Company regarding standard monitoring and auditing procedures and best practices.
  • Performs reviews of Utilization Management cases to ensure all contractual requirements have been met and all internal operational processes were followed. 
  • Plans and executes independent, objective internal audits designed to test and confirm compliance with applicable State and Federal laws.
  • Analyzes and understands regulatory requirements, and applies identified requirements to business operations when developing and conducting compliance audits.
  • Coordinates and performs audit procedures; creates work products such as audit analysis; prepares audit plan and final report summary.
  • Monitors the progress, up to the remediation, of all deficiencies once identified.
  • Supports the fulfillment of internal/external audits as required.
  • Performs other job related duties and projects as assigned.

Education/Experience:

  • Minimum 3 years’ auditing experience in a Medicaid environment.
  • High School/GED required.
  • Utilization Management and/or Case Management knowledge required, preferably with the Facets system.
  • Proficiency with Microsoft Office products (Excel, Access, and Word)
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