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Clinical Auditor: Appeals and Grievances
| Company | Healthfirst |
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| Location | New York, NY, USA |
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| Salary | $59800 – $95680 |
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| Type | Full-Time |
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| Degrees | |
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| Experience Level | Junior, Mid Level |
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Requirements
- LPN or RN license
- 1+ years of Appeals and Grievances experience
- HS Diploma or GED from an Accredited Institution
Responsibilities
- Conduct quality audits of A&G items cases grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including job aids, regulatory requirements, and case documentation including eligibility, claims, authorizations, faxes, and any additional information required to complete the audit.
- Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
- Review clinical documentation for accuracy, completeness identifying any discrepancies or non-compliance issues
- Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.
- Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
- 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
- Apply clinical and critical thinking skills to evaluate the quality and effectiveness of appeals and grievances determinations
- Additional duties as assigned
Preferred Qualifications
- Previous work experience in Appeals and Grievances in managed care plan products (e.g. Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care
- Experience working with any of the following systems: TruCare, PEGA, Citrix, RightFax, Virtual work platforms (VPN), MHS, Salesforce, OnBase
- 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, communication, attention to detail, problem-solving skills knowledge of regulatory framework and understanding of clinical practices
