Clinical Quality Specialist - (Tampa, FL)

Performs file audits of the Care Management process to evaluate contractual and regulatory adherence with case and disease management standards and / or utilization management determinations. Participates in development of audit tools, conducts file reviews with objectivity and accuracy, appropriately escalates areas of concern and participates in meeting presentations of audit results. Actively participates in departmental initiatives to ensure audit project time lines and expectations are met. Required functions: Conducts file audits as assigned for Care Management clinical adherence which includes utilization management, case management and disease management.Participates in the development and ongoing review of audit tool clinical elements that accurately capture adherence with required standards.Reviews Care Management program descriptions, policies and procedures, step actions, and training materials as well as State Contracts when needed to evaluate alignment of audit elements, departmental processes