• Care Management Quality Auditor

    Job Locations US-MI-Southfield or Kalamazoo
    Req No.
    Regular Full-Time
  • Overview

    The Care Management Quality Auditor will report directly to the Manager, Care Management Quality and Auditing to develop and oversee standards of excellence in all aspects of care coordination performance and documentation quality as well as directly supporting a constant state of audit readiness for both internal and external partners/agencies. Also, responsible for the development and implementation of standards of excellence for the care management team and further evaluates the quality of the care management team performance and documentation.


    • Perform at the direction of the Manager, Care Management Quality and Auditing, to develop and oversee activities such as establishing care management standards of excellence including but not limited to design and implementation of audit tools and performing Inter-Rater Reliability (IRR) assessments.
    • 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 care coordination performance and documentation
    • 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.
    • Establish a feedback mechanism to the managers of care management and the training function to ensure that remediation and performance management occurs in a timely fashion.
    • Escalate any concerns including, but not limited to, patient safety, clinical care risks, documentation, or compliance with regulatory requirements, to Manager, Care Management Quality and Auditing.
    • Establish oversight tools (audit and monitoring tools), policies, procedures and other process flows for quality monitoring and oversight of all care management team performance and system documentation with emphasis on timely and comprehensive care plan development and updates
    • Develop reports that assist and elevate tracking and trending of audit or monitoring results, and perform IRR related activities.
    • 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
    • Contribute to the development of guidelines, policies, and competencies
    • Deliver/ present individual or group training on care management execution standards of excellence, quality monitoring or audit findings in collaboration with training leadership and other care management leadership
    • Support the creation and maintenance of care management processes and procedures, systems workflows, training agendas and other supporting content using products such as Microsoft Visio, PowerPoint, and Excel as well as screen capture tools
    • Develop/ update new training content following policy and/ or procedure enhancements or clinical information systems/ applications upgrades as needed.
    • Interpret data gained though quality assurance process (i.e. training course evaluations) and making appropriate changes to maintain effectiveness.
    • Develop and maintain “super user” status for relevant care management team internal systems such as TruCare and Patient3D
    • Other duties as assigned


    • RN required
    • 2 years of experience as a practicing health plan care manager 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
    • Proficiency in creating formal training materials and course documentation, including electronic learning development
    • 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
    • Experience training in medical facilities, exposure to medical office procedures is a plus
    • 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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