Corporate Quality Auditor- Analyst

Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year.

We know that by serving our employees well, they, in turn, will better serve our nearly 250,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Corporate Quality Auditor/ Analyst

POSITION SUMMARY

Promotes and maintains the quality, accuracy, timeliness, and compliance with regulatory, contractual, and accreditation standards of Corporate Quality departmental activities by monitoring, auditing, and analyzing internal processes. Departmental activities include the resolution of quality of care/quality of service grievances; potential quality issues (PQIs); initial, interim, and periodic site surveys and medical record reviews; corrective action plans (CAPs) related to all Corporate Quality activities; quality reports and documents required for regulatory, contractual, or accreditation purposes; and vendor activities. Prepares summary reports and dash boards related to compliance, operations, and/or goals for the Corporate Quality department. Analyzes data and prepares reports that are incorporated into the quarterly Quality Improvement Program (QIP) report. Assists the Director with external audit preparation and follow-up. Conducts other related QA activities on an as needed basis, such as systems or software testing for the department. Improves quality through continual monitoring and process improvement.

COMPLIANCE WITH REGULATIONS:

Works closely with all necessary departments or entities to verify that the processes, programs and services are accomplished in a quality, timely, and efficient manner, in accordance with CHG internal policies and procedures and applicable state and federal regulations and accreditation standards.

RESPONSIBILITIES

• Ensures that internal, external, and regulatory timelines and requirements are met; assists the department in being “audit ready” at all times by monitoring, auditing, and analyzing internal processes related to quality of care/quality of service grievances, PQIs, site surveys and medical record reviews, and required reports and documents according to departmental policies and procedures.
• Conducts data analysis and prepares reports based on monitoring, auditing, and oversight activity. Examples include, but are not limited to, department dash boards, PQI aging report, PQI trending and analysis, and CAP tracking and follow-up report.
• Maintains an in depth and up-to-date understanding, of Department of Healthcare Services (DHCS), Centers for Medicare and Medicaid Services (CMS), Department of Managed Healthcare (DMHC), and National Committee for Quality Assurance (NCQA) regulatory, contractual, and accreditation requirements related health plans and quality.
• Maintains an in depth understanding of the policies and procedures, desktop processes, and best practice guides used by the Corporate Quality department and assists Director in the reviewing and updating of policies as necessary.
• Assists the Director in completing reports and analysis for quality improvement projects (PIPs) and studies.
• Assists in gathering, organizing, and tagging documents and files for audits and accreditation surveys.
• Receives, interprets and documents error reports and feedback from regulators and other stakeholders and monitors adherence to corrective action plans.
• Reviews and updates the Corporate Quality training manual as needed.
• Provides recommendations for staff training and assists in training based on audit findings and potential risks.
• Provides continual feedback to Director and other management staff on areas for improvement based on QA findings.
• Maintains organized and up to date logs of QA activity that include case details as well as summary level data.
• Participate in relevant interdisciplinary department meetings on an as needed basis.
• Maintains teamwork approach with Corporate Quality department staff and other CHG internal departments and vendors.
• Reviews and updates the Corporate Quality training manual as needed.

Education:

• Bachelor's Degree Required.
  

Experience/Skills:

• Two years of experience in QA or in an auditing role (preferably in the health care industry).
• Strong knowledge of standards and regulations for Department of Healthcare Services (DHCS), Centers for Medicaid & Medicare Services (CMS), Department of Managed Healthcare (DMHC), and National Committee for Quality Assurance (NCQA).
• Solid healthcare and managed care background; specifically Medi-Cal and Medicare.
• Ability to read and interpret regulations and standards.
• Excellent time management skills.
• Strong agility and adaptability to changing regulations, timelines, and requirements.
• Excellent attention to detail.
• Strong ability to manage multiple projects and tasks.
• Ability to handle confidential, sensitive information with professionalism.
• Excellent verbal, written, organizational, and analytical skills.
• Ability to retrieve information from various sources and analyze accordingly.
• Excellent organizational skills.
• Knowledge of enterprise software applications; QNXT a plus; ability to navigate internal data and systems.
• Solid healthcare and managed care background.
• Proficiency in Microsoft Office, up to and including MS Excel, MS Word, MS Publisher, MS PowerPoint, MS Access.

Physical Requirements:

• Prolonged periods of sitting.
• Prolonged use of computer.
• May be required to work evenings, weekends, and holidays.