Internal Auditor

Overview

The Internal Auditor is an important position to ensure quality case investigations within the Grievance & Appeals Department (G&A). The auditor assesses the quality of all grievance and appeal cases to ensure they meet DHCS-mandated requirements, NCQA specifications, and Partnership professional standards.  Conducts individual audits of grievance, appeal, exempts, and State Hearing cases completed by the Grievance staff. Identifies and recommends improvements to advance the overall quality of investigation outcomes.

Responsibilities

• Regularly conducts concurrent and retrospective audits of individual case investigations according to established audit criteria and provides feedback to associates as applicable
• Performs routine and timely quality assurance audits for all types of cases – grievance, appeals, exempts, and State Hearing cases conducted on a standard or expedited basis
• Assesses cases to determine if DHCS-mandated timeframes, NCQA specifications, and Partnership professional standards for member experience are met
• Determines if clinical guidance is executed accurately throughout the case investigation process
• Evaluates the quality of written communications
• Assesses accurate use of reporting fields to support DHCS, NCQA, and interdepartmental reporting interests
• Evaluates the appropriateness of referrals and determine if best resolution is offered given nature of case
• Enters audit findings of individual cases in the audit tracking database
• Provides audit findings feedback to G&A Manager and Supervisors regarding associates’ audit performance.
• Keeps current on all regulatory requirements that may influence G&A audit criteria and/or practices
• Recommends areas in need of additional training and/or close oversight based on the trending and analysis of audit results
• Makes strategic recommendation(s) to improve the accuracy, quality, and/or reporting of case investigations based on audit observations in order to enhance members’ healthcare experience
• Assists in the development and maintenance of auditing guidelines, including the audit tracking database
• To support regulatory compliance, creates and maintains desktop(s) to document policy and procedures for G&A audit practices
• Maintains strict confidentiality of members’ PHI/PII

SECONDARY DUTIES AND RESPONSIBILITIES

• May participate in special projects or initiatives as directed

Qualifications

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$42.38 - $52.97

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform.  The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.