Kelsey-Seybold

  • UM Delegation Auditor

    Location US-TX-Pearland
    Posted Date 1 week ago(6/13/2018 12:52 PM)
    Job ID
    2018-19039
    Category
    Professional
  • Overview

    UM Delegation Auditor

    Location: Pearland Administrative Office
    Job Type: Full Time
    Department: Utilization Management

     

    Company Profile

    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.​​

     

    JOB SUMMARY

    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)

    Education

    A.

    Bachelor’s Degree in Marketing, Business or equivalent

    B.

    Project Management experience

    Experience

    A.

    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,

    OR

    3+ years’ experience in Health Plan Operations (claims, delegation oversight, appeals and grievances, network development, or Utilization Review)

     

    B.

    • Utilization Review experience at a health plan or medical group
    • Healthcare claims payment experience or healthcare billing office Experience

    Licenses

    A.

    Driver’s license

    B.

     

    Special Skills

    A.

    • Microsoft Excel and Word.
    • Must meet a minimum standard of typing “35-40 WPM” on a typing test.
    • Must demonstrate the ability to clearly communicate both verbally and in writing.

     

    B.

     

    Other

    A.

    • Knowledge of state and federal Utilization review agent requirements.    
    • Knowledgeable of regulatory compliance requirements (CMS and TDI).
    • Demonstrated ability to work with confidential information.
    • Ability to effectively present information and respond to questions from peers and management.
    • Ability to work in a fast paced environment with changing priorities. 

     

    B.

     

     

    WORKING ENVIRONMENT

    Office

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