Clinical Auditor: Appeals and Grievances

Description and Requirements

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

Minimum Qualifications:

• 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.

Preferred Qualifications:

• 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

License or Certification: NYS LPN or RN license.

Regulatory or Compliance activities: n/a

Hiring Range:

• Greater New York City Area (NY, NJ, CT residents): $81,099 - $116,480
• All Other Locations (within approved locations): $71,594 - $106,080

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.