Clinical Auditor

Job ID: DM-1018593 Description:

HCSC is committed to diversity in the workplace and to providing equal opportunity and affirmative action to employees and applicants.We are an Equal Opportunity Employment / Affirmative Action employer dedicated to workforce diversity and a drug-free and smoke-free workplace. Drug screening and background investigation are required, as allowed by law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

If you are an individual with a disability or a disabled veteran and need an accommodation or assistance in either using the Careers website or completing the application process, you can email us here to request reasonable accommodations.

Please note that only requests for accommodations in the application process will be returned. All applications, including resumes, must be submitted through HCSC's Career website on-line application process. If you have general questions regarding the status of an existing application, navigate to "my account" and click on "View your job submissions".

BASIC FUNCTION:

This position is responsible for the day to day management of medical issues involving Medical Group/Individual Physician Associations (IPAs), members, providers, and vendors; assisting medical groups in following the Mental Health and clinical guidelines; assisting members in accessing mental health care; assisting members and medical groups in resolution of complex/unusual quality of care or claim issues; functioning as a liaison between Employee Assistance Program (EAP) counselors and medical groups, behavioral health vendor and managed care product networks; and educating members, medical groups, and vendors regarding split Behavioral Health benefit (dual diagnosis). Also responsible for performing on-site assessments for behavioral health and clinical services providers for state and federal regulations, and quality purposes; providing one-on-one and group trainings for providers, marketing, staff; and as assigned as nurse liaison for several medical groups, responsible for Utilization Management (UM) duties, the UM Plan, denial files, annual UM assessments for assigned Medical Group/IPAs. This position is involved in oversight of behavioral health and clinical vendor agreements including review of adherence to contract agreements and may draft amendments to agreements.

JOB REQUIREMENTS:

Bachelor's degree is required.

5 years experience in behavioral health or clinical care management.

3 years managed care experience.

Ability to interpret and knowledge of NCQA standards and URAC requirements.

Knowledge of state and federal health insurance regulations.

Organizational skills.

Verbal and written communications skills to include delivering presentations to committees and acting as company representative to providers and vendors.

PC experience to include Microsoft Office suite of applications (Word, Excel)

Able and willing to travel, including overnight stays (approximately 10% overnight travel).

PREFERRED JOB REQUIREMENTS:

Bachelor's degree in Nursing, Health Care Administration, or health care field.

Presentation application experience (such as PowerPoint) and database experience.

Project management experience including leading projects.

Requirements: Expertise Behavioral Health, Claims & Customer Service, Audit Job Type Full-Time Regular Location IL - Chicago


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