Position Purpose: The Clinical Data and Audit Consultant is responsible for the clinical content component of all data collection, account implementations, and audit activities for Clinical Operations to ensure high-quality tracking and performance of the service teams.
Key Details: Registered Nurse - Must be currently licensed in CA. Pacific Time Zone Work Hours
The Consultant gathers and analyzes data, creates workflows, coordinates internal and external audits, and analyzes and documents business processes to meet all clinical, procedural, account, and regulatory requirements.
- Demonstrates regular, reliable and predictable attendance.
- Leads various data analysis projects to examine and define potential clinically related issues and track productivity and quality measures
- Reviews, analyzes, and interprets data for required HEDIS, URAC, NCQA compliance, and related reporting for clinical service teams
- Interprets clinical data that does not conform to established/approved, required specifications, including Unity Reports, and assists in corrective action processes
- Addresses and participates in training of clinical staff resulting from data tracking and analysis efforts
- Identifies, evaluates, recommends and documents clinical business needs and objectives, operational processes and procedures, problems and requirements
- Produces documentation, including project plans, analytical reports, decision backup, information research reports, training plans, business justifications, graphics, workflow and business process models
- Recommends operational and process improvements based on efficiencies and available technologies
- Maintains a repository of performance and audit metrics, and generates management reports illustrating statistical data, text, workflows, and graphics
- Conducts secondary research using a variety of publications, services and health statistic databases
- May also be assigned lower level management functions and back up supervisors on clinical team
- Works with other departments to identify and document business requirements, workflow, policies and procedures
- Organizes and compiles cases for all External Health Net, NCQA, URAC, and Account Audits
- Participates in Quarterly Health Net Regulatory Audit meetings to assist Clinical Directors
- Supports Clinical Supervisors in tracking of monthly Care Manager audit results
- Works with Data Analysis Department to design data pulls
- Assists with generating HLOC and Outpatient Cost of Care and Target Outlier Reports including trend analysis
- Supports staffing analysis with current and forecasted requirements
- Investigates current regulations, interprets findings, and makes recommendations to Healthcare Services teams
- Conducts complex trend analysis and, based on analysis, creates Corrective Action Plans, and presents recommendations to business teams across department to improve performance
- Other duties as required
- Performs other duties as assigned
- Complies with all policies and standards
Education/Experience:
- BA/BS in Psychology, Nursing or other related clinical field; Masters in Social Work, Counseling, Nursing, or related field preferred
- Three to five years case management or related clinical experience
- Two to three years experience conducting business studies, recommending solutions and/or business analysis, preferably in Healthcare
License/Certification: Licensed Clinician and/or RN required. Must have and maintain current, valid and unrestricted clinical license.
Pay Range: $33.71 - $60.67 per hour
At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.
Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act