Clinical Auditor: Appeals and Grievances

Healthfirst; Pennsylvania; On-site; USD 59,000 - 88,000; Full time

Job summary

Join a forward-thinking company as a Clinical Auditor for Appeals and Grievances, where your expertise will ensure adherence to quality standards and regulatory requirements. In this role, you'll conduct audits, review clinical documentation, and provide valuable feedback to enhance operational efficiency. Collaborate with cross-functional teams to identify areas for improvement and contribute to a culture of excellence. This position offers a competitive salary and a comprehensive benefits package, making it an exciting opportunity for professionals passionate about quality in healthcare.

Benefits

Medical Coverage

Dental Coverage

Vision Coverage

401k Contributions

Life Insurance

Incentive Programs

Recognition Programs

Qualifications

• 1+ years of Appeals and Grievances experience required.
• LPN or RN license is mandatory for this role.

Responsibilities

• Conduct quality audits of appeals and grievances cases.
• Review clinical documentation for accuracy and compliance.

Skills

Critical Thinking

Time Management

Communication Skills

Problem-Solving Skills

Education

LPN or RN License

High School Diploma or GED

Tools

TruCare

PEGA

Salesforce

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Clinical Auditor: Appeals and Grievances

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Clinical Auditor: Appeals and Grievances

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The Appeals and Grievances Clinical Quality Auditor performs audit functions for Healthfirst 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 evaluating and ensuring compliance with internal and regulatory standards for appeals and grievances, outlining audit findings, recommending corrective actions, and effectively communicating the findings.

Duties And 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
  
  

Minimum Qualifications

• LPN or RN license
• 1+ years of Appeals and Grievances experience
• HS Diploma or GED from an Accredited Institution
  
  

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
  
  
  
  

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $67,205 - $95,680
• All Other Locations (within approved locations): $59,800 - $87,360
  
  

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.

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Accounting/Auditing and Finance

• Industries

  Hospitals and Health Care

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