Quality Auditor II

Job not on LinkedIn

🔥 12 hours ago

🏖️ New Jersey – Remote

🏖️ New Jersey – Remote

💵 $79.1k - $105.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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NJM Insurance Group

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1913

Insurance

NJM Insurance Group is a well-established insurance provider offering a range of personal and commercial insurance products. Their services include auto, homeowners, renters, condo, commercial auto, and business insurance, with a focus on exceptional customer satisfaction and claims experience. NJM is recognized for its outstanding auto claims experience by J. D. Power and is committed to serving customers in states like Connecticut, Maryland, New Jersey, Ohio, and Pennsylvania. The company prides itself on being straightforward and customer-focused, without jingles or mascots, offering trusted insurance solutions and multiple discount opportunities for various policies.

📋 Description

• 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.

🎯 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