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General Summary of Position
The Nurse Auditor, Clinical Operations MFC DC and MD will coordinate all activities associated with clinical activities, including the development and review of training, and auditing materials, performing auditing of clinical team members including but not limited to Case Management (CM) and Utilization Management (UM), and preparation for the actual and mock NCQA audits. The Nurse Auditor will perform audits to evaluate individuals' compliance with clinical processes, National Committee for Quality Assurance (NCQA) standards, regulatory requirements, and of overall clinical program effectiveness and efficiency.
The Clinical Nurse Auditor will report to and work closely with the Assistant Vice President (AVP), Clinical Operations to monitor, maintain, and support the clinical department to maintain a high level of quality performance and comply with regulatory requirements and accreditation standards.
The Clinical Nurse Auditor participates on departmental and organizational project teams and plays a critical role in project implementation by soliciting requirements through interviews, workshops, and/or existing systems documentation or procedures and ensuring that all impacted processes and systems are evaluated.
The Clinical Nurse Auditor works closely with the Clinical Department in assisting with the definition, documentation, training, and support for new required accreditation processes.
As a member of the Clinical Operations team the Clinical Nurse Auditor will have an opportunity to support improved accessibility to key business information, ensure process integrity, and develop process flexibility which contributes to the success of the organization.
The auditor will maintain current knowledge about NCQA, contract requirements, healthcare / industry trends, District regulations, and other compliance standards.
Primary Duties and Responsibilities
Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and patient care philosophy.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.Maintains current knowledge of MedStar Family Choice benefits and services available for enrollees.Conducts monthly file audits for all file requirements.Participates in and/or lead clinical Inter-rater Reliability Testing (IRR).Proactively communicates and collaborates within the Clinical Departments to identify key areas of focus and helps to develop and maintain a clinical audit plan that includes auditing, analyzing, strategizing, and developing process refinements and program improvements.Develops written summaries of specific key areas of training required for clinical staff based on audit results and works on developing programs with Clinical Operations to help clinical staff gain proficiency in their work and documentation processes.Monitors staff adherence to designated NCQA UM, NCQA Complex Care Management (CCM), contractual and regulatory requirements with ongoing assessment of performance.Works with the AVP, Clinical Operations to communicate recommendations for operational changes based on survey findings to clinical leadership.Participates in training activities for clinical staff to support adherence to NCQA and other regulatory and internal documentation standards/requirements.Participates in the training of the InterQual products for new UM staff and MD's and any updates as needed.Proctors/administers the Inter-rater Reliability Testing to applicable clinical staff.Conducts Utilization Management chart reviews to ensure that Clinical Screening Criteria (InterQual) has been applied correctly.Supports business requirements for system and process improvements.Researches pertinent information as requested.Holds self and others accountable to meet commitments.Ensures diversity, equity, and inclusion are integrated as a guiding principle.Persists in accomplishing objectives to consistently achieve results despite any obstacles and setbacks that arise.Maintain current knowledge about NCQA Standards, DHCF contract requirements, healthcare / industry trends, District regulations, and other compliance standards and demonstrate proficiency with all MedStar Family Choice software systems that support the clinical operation and participates and contribute to meetings (staff meetings, committee meetings, etc.).
Minimum Qualifications
Education
- Bachelor's degree Nursing required
Experience
- 1-2 years Case Management and utilization review experience required and
- 1-2 years Auditing required and
- 3-4 years Diverse clinical experience required
Licenses and Certifications
- RN - Registered Nurse - State Licensure and/or Compact State Licensure Valid RN license in the District of Columbia and Maryland Upon Hire required
Knowledge, Skills, and Abilities
- Skilled in planning, executing, and evaluating audit gaps and developing performance improvement initiatives
- Possess exceptional interpersonal and communication skills
- Knowledge of current trends in healthcare delivery and Case Management / utilization review criteria
- Ability to use computer to enter and retrieve data.
- Ability to create, edit and analyze (Word, Excel and PowerPoint) preferred
This position has a hiring range of $87,318 - $157,289
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MedStar Health
Aug 06, 2025