Clinical Auditing Nurse- Remote /CA license/
About us Community Health Plan of Imperial Valley (CHPIV) is committed to improving the health and well-being of our community by offering accessible, high-quality, and culturally sensitive healthcare services. We are a local health plan dedicated to making a positive impact through education, outreach, and innovative care.The Clinical Auditor plays a critical role in advancing the mission of Community Health Plan of Imperial Valley (CHPIV) by ensuring that clinical functions performed by delegated entities are in full compliance with regulatory, contractual, and clinical standards.This position directly supports CHPIV’s enterprise compliance framework by enforcing accountability with contracted partners, promoting member safety and rights, and contributing to audit preparedness for state and federal agencies.About the role Our new Clinical Auditor will do the following:• Identify care delivery breakdowns and initiate clinical quality escalations.• Ensure decisions adhere to evidence-based guidelines and meet timeliness standards.• Evaluate the quality and completeness of medical documentation and denial notices.• Monitor regulatory metrics and reporting to internal committees.• Conduct targeted reviews of member grievances, Quality of Care (QOC) cases, and appeals.• Evaluate clinical appropriateness, policy adherence, and timeliness of resolution.• Identify care delivery breakdowns and drive escalation of quality concerns.• Ensure member protections are enforced and documented per regulatory requirements.• Audit prior authorization, concurrent review, post-stabilization, and retro authorizations.• Ensure compliance with medical necessity criteria, turnaround times, and readability standards of denial notices.• Monitor and trend UM decisions against DHCS/DMHC/CMS regulations and plan policy.• Track timeliness, parity, continuity of care, and EPSDT requirements.• Ensure delegate accountability and regulatory adherence in care delivery for vulnerable populations.Aboutour next team member Our new Clinical Auditor will have the following:• LVN or Registered Nurse (RN) California license• At least 2 years of clinical or managed care experience• Experience with Medi-Cal/Medicare regulations strongly preferred• Excellent written and verbal communication skills.• Knowledge of Medi-Cal Managed Care principles and/or government programs.• 1+ year in health plan auditing or quality management• 3-5 years in a Medi-Cal managed care setting• Ability to manage multiple priorities and projects and meet deadlines.• Ability to learn quickly and work in a fast-paced environmentOur commitment to you• A competitive salary of $90,000-$110,000/ year• Health, dental, and vision insurance• Paid life and disability insurance• A 401k plan with a generous match• Paid time off• A chance to make a real difference in the Imperial Valley communityPreference will be given to local candidates; however, remote candidates in California and Texas will also be considered.We are an equal-opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.Original job Clinical Auditing Nurse- Remote /CA license/ posted on GrabJobs ©. To flag any issues with this job please use the Report Job button on GrabJobs. Apply tot his job