Clinical Quality Auditor II – RN/SW

Job Description: • 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 Apply tot his job