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Job Type
Full Time
Job Details
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
- 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.
- Relevant previous work experience such as medical records review; claims processing; utilization/case management in a clinical practice or managed care organization; managed care plan products (e.g. Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care; nursing experience in an acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA); Geriatrics, Medical Surgical Nursing, Case Management or Discharge Planning; etc.
- 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
- Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480
- All Other Locations (within approved locations): $71,594 - $106,080
About the Company
Healthfirst, Inc.
New York City, NY, United States
Healthfirst is one of the nation’s largest not-for-profit health insurers, offering members access to high-quality, affordable healthcare. The... Read more