Clinical Data Audit Consultant

Responsibilities

Demonstrates regular, reliable and predictable attendance

Leads various data analysis projects to examine and define potential clinically related issues and track productivity and quality measures

Reviews, analyzes, and interprets data for required HEDIS, URAC, NCQA compliance, and related reporting for clinical service teams

Interprets clinical data that does not conform to established/approved, required specifications, including Unity Reports, and assists in corrective action processes

Addresses and participates in training of clinical staff resulting from data tracking and analysis efforts

Identifies, evaluates, recommends and documents clinical business needs and objectives, operational processes and procedures, problems and requirements

Produces documentation, including project plans, analytical reports, decision backup, information research reports, training plans, business justifications, graphics, workflow and business process models

Recommends operational and process improvements based on efficiencies and available technologies

Maintains a repository of performance and audit metrics, and generates management reports illustrating statistical data, text, workflows, and graphics

Conducts secondary research using a variety of publications, services and health statistic databases

May also be assigned lower level management functions and back up supervisors on clinical team

Works with other departments to identify and document business requirements, workflow, policies and procedures

Organizes and compiles cases for all External Health Net, NCQA, URAC, and Account Audits

Participates in Quarterly Health Net Regulatory Audit meetings to assist Clinical Directors

Supports Clinical Supervisors in tracking of monthly Care Manager audit results

Works with Data Analysis Department to design data pulls

Assists with generating HLOC and Outpatient Cost of Care and Target Outlier Reports including trend analysis

Supports staffing analysis with current and forecasted requirements

Investigates current regulations, interprets findings, and makes recommendations to Healthcare Services teams

Conducts complex trend analysis and, based on analysis, creates Corrective Action Plans, and presents recommendations to business teams across department to improve performance

Other duties as required

Performs other duties as assigned

Complies with all policies and standards

Preferred

Masters in Social Work, Counseling, Nursing, or related field preferred

Benefits

Health insurance

401K and stock purchase plans

Tuition reimbursement

Paid time off plus holidays

A flexible approach to work with remote, hybrid, field or office work schedules

Glassdoor

3.6

Managed care health plans for Medicaid, Medicare, and Marketplace.

Saint Louis, Missouri, USA

http://centene.com

Public Company

Total Funding

unknown

2003-10-16

IPO

Leadership Team

Sarah London

Chief Executive Officer

Brian LeClaire

Executive Vice President and Chief Information Officer

Recent News

Fierce Healthcare

Urban hospitals face closure rates similar to rural facilities, study finds

2026-10-11

Hospital industry sues to block HHS' 340B rebate pilot (again)

Quartz

Millions of seniors will have fewer Medicare Advantage options as open enrollment begins

2026-10-10

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Qualifications

Registered Nurse

Must be currently licensed in CA

BA/BS in Psychology, Nursing or other related clinical field

Three to five years case management or related clinical experience

Two to three years experience conducting business studies, recommending solutions and/or business analysis, preferably in Healthcare

Licensed Clinician and/or RN required

Must have and maintain current, valid and unrestricted clinical license

Masters in Social Work, Counseling, Nursing, or related field preferred

Required skills

Registered Nurse License, Clinical Data Analysis, HEDIS, URAC, NCQA, Healthcare Auditing, Case Management, Healthcare Business Analysis, Trend Analysis, Regulatory Compliance

Experience

3-5 years