Remote Nurse Auditor Jobs in Raleigh, NC (NOW HIRING)

The Clinical Quality Analyst manages the quality review process for care management programs. Incumbents conduct quality reviews of internal data and processes to identify trends/patterns that impact service/system quality and may require interventions.

This position is fulltime remote. Selected candidate must reside in North Carolina. Some travel for onsite meetings to the Home office may be required. 

Responsibilities & Duties

Analyze Care Management documentation and activities to ensure compliance

• Review the quality-of-Care Management internal processes/plans and provider information, such as Person-Centered Plans or chart notes, for alignment with procedures and/or best practices
• Audit Care Management clinical documentation, case interventions, and, if available, staff phone recordings to ensure alignment with program descriptions, workflows, internal policies, evidence based clinical guidelines, NCQA guidelines, CMS guidelines, and regulatory guidelines (when applicable)
• Identify and escalate situations which may pose quality, compliance, and safety risks that may adversely affect business operation
• Evaluate clinical appropriateness of decisions, recommendations, and actions within Care Management documentation 
• Interpret qualitative and quantitative information to appropriately document findings
• Make recommendations for improvement related to any records reviewed and write reports of findings
• Identify system and/or operational issues hindering the attainment of quality performance standards as defined by NCQA standards, applicable state and Federal laws and regulations

Analyze Data and Report on findings

• Generate monthly Care Management Quality reports on Staff performance to submit to Directors, Managers, and Supervisors 
• Provide written feedback to Directors, Managers and Supervisors concerning quality concerns pertaining to individual performance, compliance risks/trends, root cause analysis and any system or process improvements recommended

Evaluate knowledge gaps of staff and coordinate training

• Evaluate knowledge gaps of the staff and collaborate with Care Management Leadership to coordinate learning and training opportunities with the Care Management Training team 
• Monitor training of staff for effectiveness and impact of outcomes from enhanced training

Minimum Requirements

Graduation from an accredited school of Nursing with a Registered Nurse (RN) license and three (3) years of experience providing care management to individuals in the following populations; Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)

Or

Master’s degree in Health, Psychology, Sociology, Social Work, or another relevant Human Services field from an accredited college/university with a North Carolina Clinical license (LCSW, LCMHC, LMFT, LPA) and three (3) years of experience providing care management to individuals in the following populations; Traumatic Brain Injuries (TBI), Intellectual/Developmental Disabilities (I/DD), Mental Health/Substance Use Disorders (MH/SUD), Severe Mental Illness (SMI), or Physical Health (PH)

Required experience

• Experience with Care plans, comprehensive assessments, care management interventions, and service engagement activities
• Medicaid Managed Care 
• Integrated care (behavioral and physical health)

Preferred Experience

• Auditing Clinical documentation 

Preferred Certification-

• Certified Care Manager (CCM)

Special Requirement

Current, active, unrestricted NC clinical license such as RN, LCSW, LMHC, or LMFT to practice as a health professional within the scope of licensure in the state of North Carolina.

Knowledge, Skills, & Abilities

• Knowledge of North Carolina State and Federal rules and requirements related to the service continuum in North Carolina
• Knowledge of Tailored Plan, Integrated Care and Care Management processes and regulatory requirements
• Knowledge of best and promising practices for behavioral & physical health and/or intellectual/developmental disabilities
• Microsoft Excel, Word, PowerPoint, SPSS, and Survey Monkey (or other online survey tool)
• Strong clinical skills
• Problem solving skills
• Interpersonal Skills
• Strong Analytical skills
• Problem solving and conflict resolution skills
• Strong diplomacy skills and discretion
• Highly effective communication skills
• Ability to negotiate and resolve issues with minimal assistance

Salary Range

$79,425 - $101,267/ Annually

Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity. 

An excellent fringe benefit package accompanies the salary, which includes:  

• Medical, Dental, Vision, Life, Long Term Disability
• Generous retirement savings plan
• Flexible work schedules including hybrid/remote options
• Paid time off including vacation, sick leave, holiday, management leave
• Dress flexibility

Want to learn more about what it's like work as part of the Care Management Team? Click on our video to learn more: https://youtu.be/1GZOBFx61QU