Central Health Plan Jobs (NOW HIRING)

The Healthcare Delivery Auditor supports Central Health's mission to provide access to high-quality care for underserved populations by conducting internal audits of healthcare delivery programs and clinical services. This position is responsible for evaluating the effectiveness of internal controls, operational workflows, and compliance with applicable regulations, with a focus on chart audits, service documentation, provider billing practices, and care coordination processes.The Auditor plans and performs audits across Central Health's healthcare network, which includes contracted providers, clinical affiliates, and internal health system operations. This includes reviewing medical records (chart audits) to ensure documentation supports medical necessity, aligns with billing claims, and meets regulatory and policy standards (e.g., HIPAA, CMS, Texas Medicaid, and other applicable guidelines).

Essential Functions

• Conducts risk-based audits of healthcare delivery and clinical operations, including patient chart reviews, referral processes, and encounter documentation.
• Conducts detailed audits including data collection, analysis, and testing of internal controls.
• Assesses compliance with federal and state healthcare regulations, Central Health policies, and contractual obligations with delivery system partners.
• Evaluates the effectiveness and efficiency of operations and compliance with applicable laws and regulations.
• Documents audit findings, prepares workpapers, and ensures proper evidence is maintained.
• Drafts clear and concise audit reports summarizing findings, conclusions, and recommendations.
• Monitors changes in laws, regulations, and industry standards.
• Performs risk assessments to identify areas of potential vulnerability and risk.
• Assists in the development and implementation of risk management strategies.
• Recommends improvements to policies, procedures, and systems to enhance internal controls.
• Remains up to date on best practices in audit and internal controls.
• Preforms other duties as assigned.

Knowledge, Skills and Abilities:

Healthcare Regulations and Compliance: Extensive understanding of healthcare laws, regulations, and standards such as HIPAA, OSHA, The Joint Commission (TJC), and local/state regulations. Working knowledge of healthcare regulations (e.g., CMS, Medicaid, HIPAA), documentation standards, and billing requirements. Knowledge of patient safety standards and quality improvement protocols.Risk Management Principles: Familiarity with the principles of risk management, including risk identification, assessment, mitigation, and monitoring. Understanding of risk management frameworks and methodologies, such as Failure Mode and Effects Analysis (FMEA) and Root Cause Analysis (RCA).Clinical and Operational Processes: In-depth knowledge of clinical workflows and healthcare operations, including patient care processes, medical documentation, and healthcare technologies. Awareness of potential risks inherent in clinical practices, such as medication errors, infection control breaches, and patient safety issues.Crisis Management and Emergency Preparedness: Understanding of crisis management strategies and emergency preparedness planning. Knowledge of disaster recovery and business continuity planning in a healthcare context.Data Analytics and Reporting: Knowledge of data collection, analysis, and interpretation techniques relevant to risk management. Familiarity with healthcare data systems and software used for tracking incidents, compliance, and performance metrics.Skills:Analytical and Critical Thinking: Ability to analyze complex situations, identify risks, and evaluate potential impacts. Proficiency in conducting root cause analyses, developing risk assessments, and recommending corrective actions.

Strong analytical, organizational, and communication skills, with the ability to interpret clinical data and regulatory criteria.

Communication:

Strong verbal and written communication skills for effectively conveying risk management information to diverse audiences, including healthcare staff, management, and external regulators. Ability to present findings, reports, and recommendations clearly and persuasively.Leadership and Collaboration: Ability to lead risk management initiatives and work collaboratively with interdisciplinary teams. Skilled in fostering a culture of safety and encouraging proactive risk management practices across the organization.

Project Management: Proficiency in managing multiple projects simultaneously, including the ability to plan, execute, and oversee risk management projects from start to finish. Skills in prioritizing tasks, managing time effectively, and meeting deadlines.

Problem-Solving: Ability to identify problems, generate solutions, and implement effective strategies to mitigate risks. Creative thinking to develop innovative approaches to risk reduction and quality improvement.

Education and Training: Expertise in designing and delivering risk management training programs for healthcare staff. Skills in assessing training needs, developing curriculum, and evaluating the effectiveness of training initiatives.

Abilities:Attention to Detail: Ability to notice and address small details that could lead to larger risks or compliance issues. Meticulous approach to reviewing processes, policies, and incidents to ensure thorough risk management.

Decision-Making: Ability to make informed, timely decisions in high-pressure situations, balancing risk with the organization's needs and ethical considerations. Capability to assess various options and choose the best course of action in uncertain circumstances.

Adaptability and Flexibility: Ability to adapt to changing regulations, technologies, and healthcare practices. Flexibility to respond to emerging risks and adjust risk management strategies as needed.

Ethical Judgment: Strong sense of ethics, with the ability to apply ethical principles to risk management decisions. Ability to maintain objectivity and integrity when dealing with sensitive issues and conflicts of interest.

Interpersonal Skills: Ability to build and maintain effective working relationships with colleagues, stakeholders, and external partners. Skills in negotiating, influencing, and resolving conflicts constructively.

Minimum Education:

• Bachelor's Degree (higher degree accepted) in Healthcare Administration, Public Health, Nursing, Business, or a related field

Minimum Experience:

• 3 years Experience in healthcare auditing, chart review, or compliance in a clinical or managed care setting

Preferred Licenses and Certifications:

• Certified Internal Auditor (CIA) Upon Hire Preferred
• Certified Professional Medical Auditor (CPMA), or related certification preferred Upon Hire Preferred