Quality Auditor II

This is a fully remote position, open to applicants in Connecticut, +3 more states.

📋 Description

• Perform quarterly audits of files across all business lines to ensure compliance with NCQA, URAC, and CMS regulatory standards.

• Analyze, prepare, and disseminate quarterly audit results, including error trends, to Business Unit Directors.

• Execute monthly CMS-CAPs audits against business Process Flows to assess compliance with Medicare standards.

• Record CMS-CAPs results in the SharePoint database and relay outcomes along with error-trend analysis to Directors.

• Utilize audit results to propose process improvements, changes, and educational/training initiatives.

• Act as the database administrator and oversee biannual MCG-IRR testing for clinical and medical director personnel.

• Manage and troubleshoot the testing database throughout the duration of the testing period.

• Inform staff of testing schedules, analyze final reports, and submit these reports to functional unit Directors and the Medical Management Committee.

• Carry out ad hoc file audits when new business practices are introduced to ensure compliance with Process Flows and regulatory standards.

• Fulfill additional assigned tasks and special projects as requested by management.

⛳️ Requirements

• At least three (3) years of clinical experience required.

• Valid and unrestricted NJ RN, LCSW, LMFT, LSW, or LPC license is mandatory.

• Proficient in using personal computers and Windows-based software.

• Skilled in Microsoft Office applications, including Word, Excel, and PowerPoint.

• Proficient in Microsoft Outlook.

• Familiarity with intranet and internet applications.

• Knowledge of Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects, and CMS websites.

• Exceptional verbal and written communication abilities.

• Strong analytical and problem-solving skills.

• Commitment to continuous improvement.

• Proficient in sharing information and knowledge.

• Capable of managing processes effectively.

• Strong interpersonal and client relationship skills.

• Effective presentation skills.

• Candidates must reside in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

• A Bachelor's degree is preferred.

• A minimum of three (3) years of clinical quality or audit experience is strongly preferred.

• For Medical Policy only: current RHIT, CPC, or AHIMA Certified Coding Specialist-P designation is required.

🏝️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision).

• Retirement Plans.

• Generous Paid Time Off (PTO).

• Incentive Plans.

• Wellness Programs.

• Paid Volunteer Time Off.

• Tuition Reimbursement.

• A mission-driven organization that values expertise, collaboration, and growth.

• Support for reasonable accommodation requests during the recruitment and hiring process.