Quality Auditor

Description

Job Summary:

This position is responsible for conducting quality audits for state audits, HEDIS and quality referral and complaints issues. This position is also responsible for preparing weekly, monthly, quarterly and year-end reports.

Responsibilities:

• Conducts on-site reviews at participating provider offices to assess environment, quality of physicians medical records, and compliance with documentation standards.
• Prepares appropriate documentation to summarize on-site findings with physician, providing education and discussing opportunities for improvement.
• Provides data support services to facilitate the process and analyze trends/patterns for quality improvement and health management.
• Assists the Quality Management department with various special projects and focused clinical studies.
• Performs related tasks or special studies as requested.
• Assists in training of internal client NJ Health staff, providers and vendors on programs and audit standards, both on and off site.
• In-house representative and project lead for state audits.
• Responsible for analysis of audit findings.
• Produces various reports as requested.
• Co-ordinates and manages the Corrective Action Plan (CAP) process for assigned audit type
• Conducts reaudits ensuring prior deficiencies were addressed.

Qualifications:

Education/Experience

• Requires License Practical Nurse License or an active New Jersey Registered Nurse License.

Additional licensing, certifications, registrations:1.

• Requires valid Motor Vehicle driver's license and access to an automobile.

Knowledge:

• Requires knowledge of managed care principles.
• Requires knowledge of medical terminology.
• Requires knowledge of PC's and related software.
• Prefers knowledge of URAC accreditation standards and HEDIS principles.
• Prefers knowledge of health management or patient education.

Skills and Abilities:

• Require excellent verbal and written communication skills.
• Requires excellent organization skills.
• Require strong analytical skills.
• Requires good problem solving/conflict resolution skills.
• Requires good decision making skills.
• Requires strong PC skills.
• Require strong presentation skills.