Medical Compliance Auditor - Health Plan

Medical Compliance Auditor

We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria.

Assess the treatment plan, clinical information, and medical necessity of all requested services

Consults with medical directors and clinical staff regarding patient's history and current care needs and whether services billed were appropriate.

Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action.

Telephonic follow-up with the provider's office to request additional information as needed.

Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit.

Evaluate benefit coverage and regulatory guidelines pertinent to decision making for each investigation.

Perform Clinical and Coding Review on Medical Claim Appeals.

Perform Clinical Review and make recommendation on Audit Pass/Fail.

Ongoing assessment for quality indicators and concerns.

Preferred Bachelor's Degree in Nursing

• Required 3 years Clinical experience in the applicable field according to the license (LVN or RN)
• 4 years of Medical Auditing experience.

Founded in 1996, Texas Children's Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. To join our community of 15,000+ dedicated team members, visit texaschildrenspeople.Texas Children's is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Job Schedule Full time

Job Shift Day

Texas Children's Hospital