Medical Management Auditor & Trainer

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We are transforming healthcare to be value-driven, creating a seamless, consumer-centric care experience that maximizes value for all.

We believe that all health consumers are entitled to high quality, coordinated healthcare. We uniquely align the interests of health consumers, providers, and payors to make high-quality healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.

Job Summary:
The Medical Management Auditor & Trainer evaluates and audits the medical services provided under managed care programs to ensure they are medically necessary, appropriate, and in compliance with regulatory standards.
This role involves reviewing patient care and treatment plans, auditing clinical decisions, and verifying that services align with both medical necessity and insurance company policies. Communicates findings to leadership and staff and delivers continuous training on individual corrective actions and improvements to departmental processes.

Key Responsibilities:
1. Conduct Utilization Reviews: 
o Review patient treatment plans, medical records, and healthcare services for appropriateness and adherence to managed care guidelines. 
o Perform both retrospective and concurrent reviews of medical cases to ensure that healthcare services provided align with medical necessity standards. 
o Audit the use of healthcare resources and ensure that services, such as inpatient stays, diagnostics, and procedures, are justified. 

2. Evaluate Medical Necessity and Clinical Decisions: 
o Assess the clinical appropriateness of services rendered by reviewing the patient’s health status, history, and treatment protocols. 
o Ensure that services provided meet medical necessity criteria and follow evidence-based guidelines established by the managed care organization. 

3. Regulatory and Payer Compliance: 
o Ensure that healthcare services comply with both federal and state regulations, as well as the
specific policies of managed care plans. 
o Evaluate the correct application of payer guidelines and ensure proper documentation. 

4. Documentation and Reporting: 
o Maintain accurate and thorough documentation of audit findings, including recommendations for corrective actions or process improvements. 
o Prepare detailed audit reports summarizing findings, trends, and opportunities for cost savings or improvements in care delivery. 
o Communicate audit results to relevant departments, including case management, utilization management, and senior leadership.

 
5. Collaboration and Communication: 
o Work closely with physicians, case managers, and other healthcare professionals to assess and improve utilization management processes. 
o Provide education and guidance on appropriate care utilization, proper documentation practices, and managed care guidelines. 
o Collaborate with medical directors and utilization management teams to optimize patient care and reduce unnecessary service use. 

6. Trend and Data Analysis: 
o Monitor and analyze utilization trends to identify opportunities for cost reductions, process efficiencies, and improvements in care. 
o Provide reports on trends related to high-cost services, frequent readmissions, and other areas of concern in managed care programs. 
o Recommend best practices for improving patient care while minimizing unnecessary resource utilization. 

7. Continuous Improvement and Quality Assurance: 
o Participate in quality improvement initiatives, focusing on improving the managed care utilization management processes. 
o Suggest process improvements to enhance the efficiency of the utilization management function and improve care quality. 
o Deliver training to the team or individual staff members based on audit findings or new process improvement outcomes. 
o Stay updated on industry trends, regulatory changes, and new healthcare technologies or guidelines. 

Required Qualifications: 
• Education: Bachelor’s degree in nursing, Healthcare Administration, Health Information Management, or a related field. Clinical credentials such as Registered Nurse (RN) or Licensed Practical Nurse (LPN).
• Experience: At least 2-3 years of experience in utilization management, healthcare auditing, or managed care, with a strong understanding of medical necessity and managed care systems. 
o Familiarity with utilization management concepts, including prospective, concurrent, and retrospective review processes. 
o Knowledge of payer policies and insurance coverage. 
o Understanding of quality improvement, cost management, and healthcare compliance. 
• Certifications: Relevant certifications such as Certified Case Manager (CCM) or Utilization Management Certification (CUMC). 
o Strong analytical and critical thinking abilities for reviewing medical records and identifying discrepancies. 
o Proficiency in electronic health records (EHR) and utilization management software. 
o Excellent written and verbal communication skills, including the ability to prepare detailed reports. 
o Strong organizational skills with attention to detail and the ability to manage multiple tasks simultaneously. 

Preferred Qualifications: 
• Experience with specific managed care models such as HMO, PPO, or Medicare/Medicaid programs. 
• In-depth understanding of managed care insurance. 
• Knowledge of regulatory standards, such as those set by CMS (Centers for Medicare & Medicaid Services), NCQA and/or state health departments. 
• Experience with EMR systems and prior authorization platforms.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook).