Clinical Quality Auditor
2 weeks ago
The Clinical Auditor performs audit functions for Healthfirst clinical teams (e.g. Care Management, Reassessment/Clinical Eligibility, Utilization Management, etc.) and delegated vendors and partners [within internal timeframes and deadlines] to determine operational efficiency, adherence to regulatory requirements, and achievement of quality standards. The audits may include but are not limited to listening to Care Manager phone calls; review of Uniform Assessment System (UAS) assessments, care plans, medical authorizations, and supporting documentation ensure compliance with regulatory requirements and internal policy; etc.
**Duties and Responsibilities**:
Maintains tracking tools to log audit results including areas of non-compliance and informing what areas of improvement are needed for discussion with management and/or at departmental team meetings
Assists with evaluating and analyzing aggregate quality performance data
Develops strategies for business performance improvement initiatives. This includes: identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports
Assists with creating and revising audit tools to ensure audits and reports are value-added
Applies clinical and critical thinking skills to evaluate the quality and effectiveness of case management and/or utilization review decision-making
Additional duties as assigned
**Minimum Qualifications**:
NYS LPN or RN license.
**Preferred Qualifications**:
Relevant previous work experience such as medical records review; claims processing; utilization/case management in a clinical practice or managed care organization; managed care plan products (e.g. Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care; nursing experience in an acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA); Geriatrics, Medical Surgical Nursing, Case Management or Discharge Planning; etc.
**Experience working with any of the following systems**: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, Virtual work platforms (VPN), Electronic medical record (EMR) database containing patient health information (PHI), and/or MACESS archival system.
Language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese.
Intermediate Microsoft Word, Excel, and Outlook skills
Ability to build and maintain positive relationships with cross-functional teams and interact with all levels of management.
Time management, critical/creative thinking, project management, communication, and problem-solving skills
**License or Certification**: NYS LPN or RN license.
**Regulatory or Compliance activities**: n/a
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
EEO Law Poster and Supplement
**Hiring Range**:
**Greater New York City Area (NY, NJ, CT residents)**: $81,099 - $116,480
**All Other Locations (within approved locations)**: $71,594 - $106,080
- The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.
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