Clinical Quality Auditor II – RN/SW
Job Description:
• Responsible for the quality review of claims to enhance the clinical, network, and case management services offered.
• Conduct file audits for all areas of clinical operations.
• Perform audits on claims and correspondence to determine accuracy and completeness.
• Schedule and coordinate all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs.
• Create and maintain medical consultant calendar to ensure daily coverage.
• Maintain records and prepare reports on quality audit results.
• Evaluate quality audit procedures including quality scorecards and audit point sheets.
• Respond to internal/external clinical customer complaints/appeals.
• Conduct offsite meetings to educate physicians on process improvement initiatives.
• Participate in audits based on operations requests.
• Verify all professional licenses for RN & medical consulting staff.
• Analyze, prepare, and distribute quarterly audit outcomes.
• Document CMS-CAPs results in SharePoint database.
• Conduct ad hoc file audits when new business practices are set in place.
Requirements:
• Prefers a Bachelor's degree.
• Requires a minimum of three (3) years clinical experience.
• Strongly prefers a minimum of three (3) years clinical quality or audit experience.
• Active Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required
• Requires current Registered Health Information Technologies (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist, P from the American Health Information Management (AHIMA)
• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook.
• Requires knowledge of applications: Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects and CMS web sites.
• Prefers knowledge of audit methodologies and procedures.
Benefits:
• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement
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• Responsible for the quality review of claims to enhance the clinical, network, and case management services offered.
• Conduct file audits for all areas of clinical operations.
• Perform audits on claims and correspondence to determine accuracy and completeness.
• Schedule and coordinate all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs.
• Create and maintain medical consultant calendar to ensure daily coverage.
• Maintain records and prepare reports on quality audit results.
• Evaluate quality audit procedures including quality scorecards and audit point sheets.
• Respond to internal/external clinical customer complaints/appeals.
• Conduct offsite meetings to educate physicians on process improvement initiatives.
• Participate in audits based on operations requests.
• Verify all professional licenses for RN & medical consulting staff.
• Analyze, prepare, and distribute quarterly audit outcomes.
• Document CMS-CAPs results in SharePoint database.
• Conduct ad hoc file audits when new business practices are set in place.
Requirements:
• Prefers a Bachelor's degree.
• Requires a minimum of three (3) years clinical experience.
• Strongly prefers a minimum of three (3) years clinical quality or audit experience.
• Active Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required
• Requires current Registered Health Information Technologies (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist, P from the American Health Information Management (AHIMA)
• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook.
• Requires knowledge of applications: Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects and CMS web sites.
• Prefers knowledge of audit methodologies and procedures.
Benefits:
• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement
Apply Now
Apply Now