Clinical Auditor: Appeals and Grievances

Requirements

• NYS LPN or RN license.
• In order to access the Uniform Assessment System (UAS), an unexpired NYS driver's license or NYS ID is required. If residing outside of NYS, the candidate must be able to obtain a NYS ID before commencement of employment.
• 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
• EEO Law Poster and Supplement
• Hiring Range*:
• Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480
• All Other Locations (within approve

Benefits

Additional Information

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

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