Clinical Auditor

CalOptima is a county organized health system that administers publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. With $3.2 billion in annual revenue, CalOptima serves nearly 800,000 members, delivering services through 14 health networks. For the past four years, CalOptima has been rated the top quality Medi-Cal plan in California, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Ratings 2018–2019.

Position Summary:
The Clinical Auditor will conduct routine oversight, monitoring and auditing, of externally delegated functions to ensure compliance with state, federal, and accreditation standards.

Position Requirements:
 Bachelor’s degree in Health Sciences, Public Health, Health Administration, Nursing or other related field; or equivalent combination of education and work experience required.
 Minimum current, unrestricted LVN license to practice in the state of California is required, RN preferred.
 Minimum 2 years of experience in utilization management or equivalent experience required.
 At least 1 year of experience in a health care delivery system, including health plan, medical group, or hospital management preferred.
 Valid California driver’s license and vehicle, or other approved means of transportation, and an acceptable driving record will be required for work away from the primary office 25% of the time or more.

CalOptima’s Clinical Auditor must work to:
 Work independently, while having excellent time management and organization skills. Applicant must also be able to prioritize, manage multiple tasks, and have strong attention to detail.
 Organize and administer a complex project plan for the achievement of organizational and audit and oversight goals and objectives.
 Demonstrate and motivate others in effective team coordination and cooperation.
 Establish and maintain effective working relationships with all levels of staff, other programs, agencies and the public.
 Assist in the formulation of policies and procedures; understand and interpret policies, procedures and regulations.
 Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Services.

CalOptima’s Clinical Auditor must have the ability to:
 Legislative, regulatory and utilization management and quality requirements for health care service delivery to beneficiaries of the following programs: Medi-Cal, Cal MediConnect, and Medicare.
 Managed care compliance for Medi-Cal and Medicare.
 Principles and techniques of project management to ensure that numerous goals, objectives and detailed actions are properly identified, and their status monitored.
 Principles and practices of managed health care, health care systems, and medical administration.
 Clinical criterial application/sources and utilization management processing of prior authorization requests, as well as retrospective and concurrent requests.

Application Process
For a complete job description and to apply online, please go to www.caloptima.org. Questions can be directed to Debbie Neal, Senior Recruiter, 657-235-6891 or dneal@caloptima.org.

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