• Delegation Oversight/Clinical Auditor

    Job Locations US-CA-Aliso Viejo
    Req No.
    Regular Full-Time
  • Overview

    The Delegation Oversight/Clinical Auditor will report directly to the AVP Delegation Oversight/Clinical Audit to oversee delegated audit functions. Responsibilities include audit coordination as well as documentation and monitoring of corrective action plans. This role will work closely with the Utilization Management (UM)and Care Management (CM) teams regarding auditing functions, clinical policy and corrective action plans.


    • Prepares for and participates in external clinical auditing functions. This includes delegation oversight, state waiver, accrediting and regulatory audits. Preparation includes pre-audit of universe to evaluate for any deficiencies and communicate with appropriate department leadership.
    • Coordinates audit logistics and collaborates with health plan staff as well as internal staff, including UM and CM.
    • Prepares required documents and member specific information to be audited.
    • Documents any issues identified during the audit. In collaboration with the AVP and department leadership, develops corrective actions, reviews with appropriate internal representatives and submits documents to appropriate external entities for review.
    • Collaborates with department leadership and auditors on initiatives required to remediate audit findings. Tracks completion and submission of deliverables related to corrective actions.
    • Develop and document policies and processes related to UM and CM in collaboration with Program Management staff.
    • Recommends processes that align with contractual and regulatory operational requirements.
    • Supports technology development and enhancements by defining business specifications/requirements to meet accrediting, regulatory and health plan partner requirements.
    • Assists in the development of utilization management and care management policies, procedures or other job aides as needed, in collaboration with department leadership.
    • Develops and maintains collaborative relationships with internal staff.
    • Coordinates proposed process changes with appropriate department leaders to ensure consistent processes for all Concerto health plan partners when feasible.
    • Assists with other projects as needed.
    • Acquire and maintain relevant clinical, technical, and information systems knowledge (TruCare, Patient 3D, etc.) and utilize such internal systems knowledge to develop and monitor the quality of work.
    • Design, deliver, evaluate and track quality performance and documentation in accordance with the regulatory standards for which the Company is contractually obligated (e.g. three-way contract between the State, CMS and health plan), accepted standards of care management and care coordination practices, the applicable Model(s) of Care, the delegated arrangement and company policies and procedures, including tracking and trending audit and monitoring results.
    • Present as a positive role model in promoting clinical care coordination excellence.
    • Attend onsite visits and/ or meetings as needed or requested to assess current knowledge base and assist with remediation and performance improvement initiatives.
    • Other duties as assigned.


    • RN required
    • 2 years of experience as a practicing health plan care manager, utilization management nurse or auditor
    • Bachelor’s degree strongly preferred
    • Ability to work in a fast paced, dynamic environment and work well with others on a team
    • Demonstrate ability to perform multiple concurrent tasks with minimal supervision and meet deadlines
    • Demonstrate a sound understanding of contemporary healthcare with strong focus on clinical practice and clinical information systems/ applications
    • Strong presentation skills and good verbal and written communication skills
    • Customer service oriented
    • Computer literate – proficiency in operating personal laptop, projector, learning management system, and other trainer tools
    • Proficient in Microsoft Office Suite
    • Proficiency in clinical information systems (i.e. electronic health records)
    • Excellent planning and organization skills
    • Possess a professional demeanor and appearance


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