Clinical Quality Auditor II – RN/SW
NJM Insurance Group
full-time
Posted on:
Location Type: Remote
Location: New Jersey • United States
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Salary
💰 $79,100 - $105,945 per year
About the role
- Responsible for the quality review of claims to enhance the clinical, network, and case management services offered.
- Conduct file audits for all areas of clinical operations.
- Perform audits on claims and correspondence to determine accuracy and completeness.
- Schedule and coordinate all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs.
- Create and maintain medical consultant calendar to ensure daily coverage.
- Maintain records and prepare reports on quality audit results.
- Evaluate quality audit procedures including quality scorecards and audit point sheets.
- Respond to internal/external clinical customer complaints/appeals.
- Conduct offsite meetings to educate physicians on process improvement initiatives.
- Participate in audits based on operations requests.
- Verify all professional licenses for RN & medical consulting staff.
- Analyze, prepare, and distribute quarterly audit outcomes.
- Document CMS-CAPs results in SharePoint database.
- Conduct ad hoc file audits when new business practices are set in place.
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 applications: 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
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical experienceclinical quality auditfile auditsquality audit proceduresquality scorecardsaudit point sheetsprocess improvementdata analysismedical consultingrecord maintenance
Soft Skills
communicationcoordinationproblem-solvingcustomer serviceeducationorganizational skillsattention to detailteam collaborationleadershipadaptability
Certifications
Bachelor's degreeActive Unrestricted NJ RN LicenseLCSW LicenseLMFT LicenseLSW LicenseLPC LicenseRegistered Health Information Technologies (RHIT)Certified Professional CoderCertified Coding SpecialistCertified Case Manager (CCM)