Clinical Provider Auditor II in a hybrid role at Elevance Health examining claims and collaborating to prevent fraud. Requires coding certification and auditing experience with a focus on compliance and training associates.
About the role
- LTSS Contract Adherence Auditor ensuring compliance with state laws and contract requirements. Responsible for audits, adherence tracking, and staff education within a virtual role based in Tennessee.
Responsibilities
- Participating in auditing and contract adherence activities to ensure the Long Term Services and Supports program adheres with applicable state laws and contractual requirements
- Prepares and ensures completion of internal and external audits, adherence reporting and tracking/monitoring processes as assigned
- Audits LTSS work to ensure appropriate and consistent administration of contract requirements
- Performs external audits including enrollee record review, new member and short term stay, MCO to MCO, Level of Care and Employment and Community First audits
- Responds to on demand state audit requests
- Responsible for Annual Quality Survey and Annual Network Audit reviews, audit participation and presents audit results
- Provides internal Person Centered Support Plan auditing and comprehensive adherence auditing
- Documents audit findings in a timely, accurate and concise manner
- Tracks activities such as daily critical incident submissions, short term stay, Individual Experience, Employment and NCI surveys and caseload tracking
- Ensures clinical licensure adherence with contract requirements
- Completes monthly reports such as short term stay, caseload staffing and ratio reporting
- Responds to legislative inquiries and other on demand request per contract agreement
- Maintains knowledge of tracking tools and databases, and prepares reports to document contract adherence issues
- May educate staff about contract requirements to ensure contract adherence
- Participates in projects, initiatives and process improvement activities
- May serve as an internal resource, mentor and coach for new associates
Requirements
- Requires BA/BS and RN, LPN/LVN, LSW, LCSW, LMSW, LBSW, BSW, or MSW in accordance with applicable state law and minimum of 2 years related experience
- Licensed clinicians hired into this role require current, unrestricted RN, LPN/LVN, LSW, LCSW, LMSW, LPC, or LBSW (as allowed by state law) in applicable state(s)
- LTSS experience preferred
- Computer experience including Microsoft Office Suite including Outlook, Word and Excel preferred
Benefits
- Merit increases
- Paid holidays
- Paid Time Off
- Incentive bonus programs
- Medical benefits
- Dental benefits
- Vision benefits
- Short and long term disability benefits
- 401(k) +match
- Stock purchase plan
- Life insurance
- Wellness programs
- Financial education resources
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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