Quality Auditor II

Job not on LinkedIn

🔥 1 minute ago

🦌 Connecticut, New Jersey, +2 more states – Remote

🦌 Connecticut – Remote 🏖️ New Jersey – Remote 🗽 New York – Remote 🔔 Pennsylvania – Remote

💵 $79.1k - $105.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Horizon Connect @ Wall BCBSNJ

WebsiteLinkedInAll Job Openings

2 - 10 employees

⚕️ Healthcare Insurance

🏥 Healthcare

Healthcare Insurance • Healthcare

Horizon Connect @ Wall BCBSNJ is a LinkedIn presence or local program/office associated with Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). Based on the name and context, it appears to be connected to Horizon BCBSNJ’s health insurance operations and local outreach or member/provider engagement in the Wall, NJ area. Publicly available information provided is limited and mostly LinkedIn site chrome rather than a company profile, so this description is conservative and based on the affiliation indicated by the name.

📋 Description

• Conduct quarterly file audits for all lines of business against business Process Flows to determine compliance with NCQA, URAC and CMS regulatory standards • Analyze, prepare, and distribute quarterly audit outcomes and error trends to Business Unit Directors • Conduct monthly CMS-CAPs audits against business Process Flows to evaluate compliance with Medicare standards • Document CMS-CAPs results in SharePoint and communicate outcomes and error-trend analyses to Directors • Use audit outcomes to support process-improvement recommendations, process changes, and education/training • Serve as database administrator and facilitate biannual MCG-IRR testing for clinical and medical director staff • Maintain and troubleshoot the testing process, notify staff of testing dates, analyze final reports, and submit reports to Directors and the Medical Management Committee • Conduct ad hoc file audits when new business practices are implemented • Complete other assigned functions and special projects

🎯 Requirements

• Minimum three (3) years of clinical experience • Active unrestricted NJ RN, LCSW, LMFT, LSW or LPC license required • Proficiency with personal computers and Windows-based software, including MS Office (Word, Excel, PowerPoint) and Microsoft Outlook • Knowledge of intranet and internet applications • Knowledge of Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects and CMS websites • Excellent verbal and written communication skills • Analytical & Problem Solving • Continuous Improvement • Information & Knowledge Sharing • Process Management • Interpersonal & Client Relationship • Presentation • Bachelor's degree preferred • Minimum three (3) years of clinical quality or audit experience strongly preferred • Knowledge of audit methodologies and procedures preferred • MEDICAL POLICY ONLY: Current RHIT or Certified Professional Coder designation from AAPC or Certified Coding Specialist, P from AHIMA required

🏖️ Benefits

• Comprehensive health benefits (Medical/Dental/Vision) • Retirement Plans • Generous PTO • Incentive Plans • Wellness Programs • Paid Volunteer Time Off • Tuition Reimbursement