UM Delegation Auditor
Location: Pearland Administrative Office
Job Type: Full Time
Department: Utilization Management
Kelsey-Seybold Clinic. Your Doctors for Life.
Since 1949, Kelsey-Seybold Clinic has served its patients with one goal in mind – combine the expertise of physicians in a variety of medical specialties, with the close personal care of a family doctor. Kelsey-Seybold is Houston’s largest community-based physician group, caring for more than 400,000 patients. With 19 clinic locations, we are growing to meet the health care needs of our diverse patient population. Our mission is to provide our team members with exceptional opportunities for professional and personal growth.
The Delegation Auditor is responsible for auditing utilization management metrics and utilization review agent criteria to ensure we maintain our delegated standing with insurance companies and comply with all TDI and CMS requirements for a Texas licensed URA. This individual will compile data and track trend data over time to determine if performance standards are being met. The Delegation Auditor is responsible for performing internal audits to determine if the department is complying with the delegation criteria set forth by the applicable health plan in the delegation contracts. The auditor will conduct continuous analysis of compliance findings and progress on correcting internal deficiencies. Supports the Manager and Supervisor with the development and implementation of corrective action plans.
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
Bachelor’s Degree in Marketing, Business or equivalent
Project Management experience
3+ years’ experience in a Managed Care environment (MSO, ACO, Medical Group, health plan, IPA) as an internal auditor for delegated services, healthcare organization utilization management role,
3+ years’ experience in Health Plan Operations (claims, delegation oversight, appeals and grievances, network development, or Utilization Review)