Special Selection Applicants: Apply by 07/27/2021. Eligible Special Selection clients should contact their Disability Counselor for assistance.
The description and qualifications of this position have been slightly modified as of 8/2/2021.
The Senior Auditor within UC San Diego Health's Population Health Services Organization will act as auditor liaison with Health Plans (HP) making sure that all delegated programs meet NCQA, HP, Department of Managed Health Care (DMHC), state and federal regulatory requirements. This person will be on point for each HP with annual audits and any corrective action follow up, along with performing all file submissions timely ensuring accuracy and working with I.S. if there are problems with the templates. In addition, this person will make necessary policy changes, submit for UM committee sign-off and any staff training as a result of new requirements. Mock audits will be done looking at work flows, letter templates, adherence to all standards and documentation so we are are in compliance and pass all annual audits without issues.
Applies extensive knowledge of quality data analysis and/or improvement (QI) concepts, methodologies, and data collection and abstraction techniques to substantial projects of large scope and high degrees of complexity.
Eleven (11) years or more of relevant experience, OR Bachelor's degree in nursing or other relevant area and seven (7) years or more of relevant experience.
Relevant experience must include at least three (3) years of Health Plan auditing.
Experience and proven success with in-depth knowledge of QI standards, clinical chart review and abstraction, and regulatory requirements.
Experience with and working knowledge of National Committee for Quality Assurance (NCQA) quality standards.
Must possess excellent interpersonal and communication skills.
Must be able to work within a team environment.
Master's Degree in Nursing or relevant area.
Previous work experience with HMOs.
Must be able to work various hours and locations based on business needs.
Employment is subject to a criminal background check and pre-employment physical.
UC San Diego is an academic powerhouse and economic engine, recognized as one of the top 8 public universities by U.S. News and World Report. Innovation is central to who we are and what we do. Here, students learn that knowledge isn't just acquired in the classroom - life is their laboratory. UC San Diego's rich academic portfolio includes six undergraduate colleges, five academic divisions and five graduate and professional schools. The university's award-winning scholars are experts at the forefront of their fields with an impressive track record for achieving scientific, medical and technological breakthroughs.