Why join EXL?
At EXL, we’re more than just an analytics, operations management, and technology Company. We focus not only on our outstanding Team Members, but on our growing industry as well.
Headquartered in NYC, EXL has more than 27,000 professionals situated in locations throughout the United States, Europe, Asia, Latin America, and South Africa.
Our EXL Team Members receive the benefit of:
Valuable Compensation Package:
Comprehensive Health & Welfare Benefits:
Inviting Culture & Team-Oriented Philosophy:
The Quality Audit Specialist is a member of the Quality, Training and Accreditation Department, dedicated to performing audits and supporting the education and professional development of clinical staff processes across the organization in accordance with the regulatory or oversight body governing the applicable line of business.
• Develops and implements a schedule of internal audits that reflect that requirements and standards of the accreditation and regulatory agencies that govern our business, including but not limited to NCQA and URAC, CMS, State Medicaid offices, and state Departments of Insurance.
• Develops and implements an internal audit program for evaluating clinical quality for specific programs, including but not limited to Utilization Management, Case/Disease Management, DSMP and other HI/EXL clinical programs.
• Based on audit findings, identifies actual or potential risks, and collaborates with business leaders to resolve deficiencies through training, policy changes, additional monitoring or other actions to ensure complete remediation.
• Stays abreast of industry changes in clinical practice guidelines, regulatory and accreditation requirements and other industry guidance and identify those that impact HI/EXL or our clients
• Collaborates with the training team to contribute content, and/or conduct training for new hire and ongoing staff on compliance requirements and controls, and audit requirements.
• Collaborate with the training team and clinical leaders to provide clinical training opportunities for updates on clinical topics relevant to HI/EXL programs.
• Support external audits and due diligence activities. May include the collection, preparation, review, and submission of information, data, and documents to Manager, regulators, or auditors; accurate tracking; recordkeeping; scheduling or coordinating facilities or interviews; working with or supporting auditors; reporting; and creating/delivering presentations.
• Coordinate with or assist the Manager in preparing status and operational monitoring reports for senior management and Compliance Committees. Compile data and analyze for accuracy; identify any trends or issues and bring to Manager’s attention.
• Collaborate with the Compliance department to remediate any deficiencies identified by an external audit or client, including participation in all corrective action activities.
• Develop internal Process Improvement Plans as appropriate, determine root cause and impacts, track and monitor to ensure that actions taken effectively address short- and long-term corrections, validate that improvement actions are successfully implemented. Review and evaluate the effectiveness of improvement plans and provide comprehensive follow-up to supervisor.
• Review and edit policies and procedures related to Quality or Compliance activities as needed to maintain current and accurate documentation.
• Communicate the status of operational projects to supervisor, internal individuals and/or teams, and external clients, in a timely and proactive manner.
• Other related duties as assigned to meet departmental and Company objectives.
• Knowledge of Medical and/or Behavioral Health Case Management, Disease Management, and/or Medical and Behavioral Utilization Management Medical Necessity practices within a health plan and insurance provider environment
• Knowledge of CMS, NCQA and URAC requirements = in the health plan environment
• Experience with face-to-face and web based large group presentations for adult learners
• Critical thinking, ease in communicating in formal and informal settings, excellent documentation skills (Excel, Word, email, in-person)
• Experienced skill level working in Milliman Care Guidelines (MCG), CMS and ASAM clinical criteria sets, and the regulations surrounding the application thereof
• Ability to work independently
• Ability to analyze information and convert related activities into a comprehensive work plan with associated corrective action requirements, re-measurement for improvements as well as follow up documentation of education
• Ability to create and maintain a process improvement for all audit deficiencies, track and trend improvement or decline and manage the corrective action process accordingly
• Bachelor’s Degree, or Associate Degree in Science of Nursing
• RN - Active and unrestricted license in the state of residence
• Certified Case Manager (CCM), strongly preferred
• Certified Health Care Compliance or Quality preferred
Work Experience Requirements:
• Minimum 5 years experiences in health care managed care setting, with leadership experience preferred
• Minimum 2 years’ experience with clinical audit practice using accreditation and regulatory standards.
• One year experience with creating and managing remediation projects including training and monitoring of results