Clinical Auditor: Appeals & Grievances Advisor

Healthfirst; New York (NY); Hybrid; USD 71,594 - 116,480; Full time

Benefits offered by this job

Medical, dental, and vision coverage

401(k) contributions

Incentive and recognition programs

Job summary

Healthfirst in New York is seeking a Clinical Auditor to perform audit functions for clinical teams and partners, focusing on operational efficiency and regulatory compliance. The ideal candidate will have a NYS LPN or RN license, strong clinical judgment, and relevant experience in healthcare settings.

The role includes conducting audits, maintaining tracking tools, and developing performance improvement strategies. A comprehensive benefits package is offered, including medical, dental, and vision coverage.

Qualifications

• NYS LPN or RN license required.
• Unexpired NYS driver's license or ID needed.
• Experience in clinical practice or managed care is a plus.

Responsibilities

• Perform audits for operational efficiency.
• Conduct reviews of Care Manager phone calls.
• Analyze quality performance data.

Skills

Clinical and critical thinking skills

Strong time management

Project management

Communication skills

Problem-solving skills

Education

NYS LPN or RN license

Tools

CareEnhance Clinical Management Software (CCMS)

TrueCare

Electronic Medical Record (EMR)

Job description

Healthfirst in New York is seeking a Clinical Auditor to perform audit functions for clinical teams and partners, focusing on operational efficiency and regulatory compliance. The ideal candidate will have a NYS LPN or RN license, strong clinical judgment, and relevant experience in healthcare settings.

The role includes conducting audits, maintaining tracking tools, and developing performance improvement strategies. A comprehensive benefits package is offered, including medical, dental, and vision coverage.