Clinical Auditor – Appeals and Grievances

🕒 February 17

🗽 New York – Remote

🗽 New York – Remote

💵 $81.1k - $116.5k / year

⏰ Full Time

🟢 Junior

🔎 Auditor

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Healthfirst

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1993

⚕️ Healthcare Insurance

💸 Finance

Healthcare Insurance • Finance • Medicare

Healthfirst is a health insurance provider dedicated to helping New Yorkers access affordable health coverage for individuals and families. With over 30 years of experience, Healthfirst offers a range of plans including Medicaid managed care, Medicare Advantage, long-term care, and essential health plans. The company focuses on providing quality healthcare options, comprehensive benefits, and support to ensure members can maintain their health and well-being.

📋 Description

• performs audit functions for Healthfirst clinical teams and vendors • maintains tracking tools to log audit results • assists with evaluating and analyzing aggregate quality performance data • develops strategies for business performance improvement initiatives • assists with creating and revising audit tools • applies clinical and critical thinking skills to evaluate quality and effectiveness of case management

🎯 Requirements

• NYS LPN or RN license • unexpired NYS driver's license or NYS ID (if residing outside of NYS, must obtain a NYS ID before employment) • relevant previous work experience (e.g. medical records review; claims processing; utilization/case management) • knowledge of Department of Health (DOH) and Local Department of Social Services and CMS regulations • nursing experience in acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA) • experience with systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, EMR, MACESS • language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese • intermediate Microsoft Word, Excel, and Outlook skills • time management, critical/creative thinking, project management, communication, and problem-solving skills

🏖️ Benefits

• medical • dental • vision coverage • incentive and recognition programs • life insurance • 401k contributions