More Than 100 Years of Earning Trust
Quality Auditor II
Location
New Jersey
Posted
3 days ago
Salary
$79.1K - $105.9K / year
Seniority
Senior
Job Description
Quality Auditor II
NJM Insurance Group
• Responsible for conducting file audits for all areas of clinical operations. • Conduct quarterly file audits for all lines of business against business Process Flows to determine compliance with regulatory standards according to NCQA, URAC and CMS. • Analyze, prepare, and distribute quarterly audit outcomes including error trends, to the Business Unit Directors. • Conduct monthly CMS-CAPs audits against business Process Flows in order to evaluate compliance with Medicare standards. • Primary responsibility for documentation of CMS-CAPs results in SharePoint database and generation of communication/notification to Directors regarding the outcome including the analysis of error trends. • Serves as database administrator and facilitates biannual MCG-IRR testing (Milliman Care Guidelines-Inter Rator Reliability) that is administered to clinical and medical director staff. • Conduct ad hoc file audits against business process flows when new business practices are set in place to monitor adherence to Process Flow as it relates to regulatory compliance. • Completes other assigned functions, including special projects, as requested by management.
Job 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 the following applications, which include but not limited to: 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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