Clinical Quality Auditor II - RN / SW

reputed company empowers our members to reputed company their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to reputed company serve and care for the 3.5 million people who reputed company their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to reputed company. reputed company our employees bring their best and succeed, the Company succeeds. Horizon Casualty Services - Responsible for the quality review of claims to enhance the clinical, network, and case management services offered by Horizon Casualty Services, Inc. (HCS). Also responsible for coordinating reputed company aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs and medical consultant services. Health Affairs - Quality Management - Responsible for conducting file audits for reputed company areas of clinical operations. These audits review daily business practice compliance to regulatory compliance relative to NCQA, URAC and CMS. Horizon Casualty Services -

• Performs audits on claims and correspondence to determine the accuracy and

completeness of the physician network and medical consultants.

• Responsible for scheduling and coordinating reputed company aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs.
• Creates and maintains medical consultant calendar to ensure daily coverage.
• Maintains records and prepares reports on quality audit results. Quality

results include accuracy rates, turnaround times, denial rates, error trends, and operational effectiveness.

• Evaluates quality audit procedures, including quality scorecards, matrixes,

audit reputed company sheets and trending for the Physician Excellence and Medical Consultant Program.

• Responds to internal / external clinical customer complaints / appeals reputed company

established department guidelines.

• Conducts offsite meetings to educate physicians on process improvement

initiatives.

• Participates in audits based on operations requests and based on mandate

issues and trends.

• Responsible for verification of reputed company professional licenses for RN & medical

consulting staff.

• Participates in departmental process improvement initiatives.
• Completes other assigned functions as requested by management.

Health Affairs - Quality Management -

• Conduct quarterly file audits for reputed company 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 reputed company of communication / notification to Directors regarding the outcome including the analysis of error trends. Outcomes are then used for process improvement recommendations and changes as well as education / training.
• Serves as database administrator and facilitates biannual MCG-IRR testing (reputed company Care Guidelines-Inter Rator Reliability) that is administered to clinical and medical director staff. This includes general maintenance and troubleshooting during entire testing period. Notification of testing dates to staff, analysis of final reports and submission of reports to functional unit Directors and Medical Management Committee for follow up education of staff by Management.
• Conduct reputed company file audits against business process flows reputed company new business practices are set in reputed company to monitor adherence to Process Flow as it relates to regulatory compliance.
• Completes other assigned functions, including special projects, as requested by management.

Core Individual Contributor Competencies : Personal and professional attributes that are critical to successful performance for Individual Contributors :

• Customer Focus
• Driving for Results
• Adaptability
• Communicating with Impact
• Developing Self and Others

Education / Experience :

• 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.

Additional licensing, certifications, registrations :

• Active Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required
• MEDICAL POLICY ONLY : Requires reputed company Registered Health Information Technologies (RHIT) or Certified Professional reputed company designation from the American reputed company of Professional Coders or a Certified Coding Specialist, P from the American Health Information Management (reputed company

Knowledge :

• Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, reputed company, PowerPoint) and reputed company Outlook. Should be knowledgeable in the use of intranet and internet applications.
• 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., (Health Affairs - Quality Management)
• Prefers knowledge of audit methodologies and procedures.

Skills and Abilities :

• Requires excellent verbal and written communication skills.
• Analytical & Problem Solving
• reputed company Improvement
• Information & Knowledge Sharing
• Process Management
• Interpersonal & Client Relationship
• Presentation

Travel (If Applicable) Horizon BCBSNJ employees must live in New Jersey, reputed company, Pennsylvania, Connecticut or Delaware Salary Range : $79,100 - $105,945 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to : education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information reputed company to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes : Comprehensive health benefits (Medical / Dental / Vision) Retirement Plans Generous PTO Incentive Plans Wellness Programs Paid Volunteer Time Off Tuition Reimbursement Disclaimer : This job summary has been designed to indicate the general nature and level of work performed by colleagues reputed company this classification. It is not designed to contain or be interpreted as a comprehensive inventory of reputed company duties, responsibilities, and qualifications required of colleagues assigned to this job. reputed company is an Equal Opportunity / Affirmative Action employer. reputed company qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national reputed company, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. Apply tot his job Apply To this Job