Quality Assurance Clinical Auditor (Remote)

Date: Jan 18, 2023

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 8519 


Position Summary/Position


Under the general direction of the Manager, Regulatory Oversight, CalAIM, the Quality Assurance Clinical Auditor is responsible for oversight and monitoring of CalAIM and PHM Strategy programs such as Enhanced Case Management (ECM), Integrated Transition of Care (ITC), Community Supports (CS), and NCQA (CCM, LTSS, Health Equity) ensuring regulatory compliance. This position will require the use of quality auditing tools for auditing, conducting root cause analysis, identification of potential trends through root cause analysis and training topics based on trends. With the support of the Manager, this role will work closely with the internal and external Health Services Departments, Quality Management NCQA Team, and Compliance Team to ensure that Health Services operations support regulatory compliance and quality outcomes.

Major Functions (Duties and Responsibilities)


1. Stay current on all regulatory guidelines, i.e., DHCS, CMS, NCQA, DMHC which direct NCQA and CalAIM policies and processes and updates file review tools as appropriate.
2. Perform retrospective file reviews for ECM, ITC, CS, and NCQA populations such as, CCM, Health Equity, LTSS Distinction and Covered California, to identify significant and problematic quality issues and concerns. Perform root cause analysis and develop corrective action plan(s) to correct deficiencies.
3. Aid in implementation of new processes or protocols as required by the corrective action plan to meet IEHP and regulatory standards through the collaboration with ECM, ITC, CS, and NCQA Teams and NCQA specific program teams.
4. Ensure accuracy of job aids and resources to identify areas of learning opportunities for staff through the collaboration with ECM, ITC, CS, and NCQA Teams and NCQA specific program teams 
5. Provide recommendations towards the development of reports and studies that will aid in the evaluation of ECM, ITC, CS, and NCQA activities and improve outcomes.
6. Develop process changes to improve the ECM, ITC, CS, and NCQA delivery processes as indicated in report and study outcome through research and collaboration.
7. Participate in regulatory audits, audit preparedness and process meetings as required
8. Analyze, assess, and evaluate data in comparison to evidence-based guidelines to ensure regulatory compliance and quality outcomes.

Experience Qualifications


A minimum of two (2) years of experience in a health care setting. A minimum of two (2) year of experience in a managed care setting and in audits and/or quality and/or compliance.

Education Qualifications


Associate’s degree from an accredited institution required. 

Preferred Education

Bachelor's degree from an accredited institution preferred.

Professional Certification


Certification in Compliance (CHC), CCM, CPHQ is preferred. 

Professional Licenses


Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required.

Possession of an active, unrestricted, and unencumbered Clinical Social Worker (LCSW) license or Marriage and Family Therapist (LMFT) license issued by the California Board of Behavioral Sciences preferred.

Drivers License Required

Yes, must have a valid California Driver's License.

Knowledge Requirement


Knowledge of health plan regulations (DHCS, CMS, DMHC and NCQA). Knowledge of the Health Services Programs. Knowledge of Lean principles to problem solve and evaluate program effectiveness. Knowledge of Population Health Management, with heavy focus on CalAIM. Familiar with policy reviews and editing, auditing and summarizing findings, and Quality Assurance reviews. 

Skills Requirement


Excellent verbal and written communication skills and public speaking. Proficient in Microsoft products – Excel, Access, Power Point and Word. Excellent interpersonal, facilitation, and collaboration skills. Excellent time management skills. Excellent critical thinking skills and ability to utilize evidence-based practice guidelines.

Abilities Requirement


Ability to organize and follow through. Must be able to prioritize and meet deadlines. Resilient and able to adapt to change.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

A reasonable salary expectation is between $79,809.60 and $101,774.40, based upon experience and internal equity.

Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region, designated as “Great Place to Work.” With a provider network of more than 5,000 and a team of more than 3,000 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award-winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and stellar benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.

Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles