Quality Audit Specialist

W3R Consulting; Nashville (TN); Hybrid; USD 60,000 - 80,000; Full time

Job summary

W3R Consulting in the United States is seeking a skilled Registered Nurse or Licensed Practical Nurse to perform structured chart audits and HEDIS abstraction for healthplan reporting. You will maintain accuracy, confidentiality, and regulatory compliance while entering audit results into the healthplans database.

The role requires 3+ years of relevant experience, strong knowledge of HIPAA, and proficiency in Word and Excel.

Qualifications

• Higher education in nursing with an active, unrestricted license (RN or LPN).
• Minimum 3+ years in utilization review, QA, or medical record audits.
• Experience with HEDIS abstraction is preferred.
• Strong knowledge of HIPAA and regulatory standards.
• Excellent verbal and written communication; proficient in Word and Excel.

Responsibilities

• Apply structured auditing criteria to abstract medical records and enter results into the healthplans database.
• Abstract medical record documentation for HEDIS measures used for NCQA reporting.
• Maintain productivity with less than 5% error rate in record abstraction and data entry.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, and other policies.
• Maintain confidentiality of company information and communicate with management as needed.
• Perform special projects as required.

Skills

Utilization review experience

Quality assurance

Medical record audits

HIPAA compliance

Communication skills

Word/Excel proficiency

Education

RN or LPN license (unrestricted)

3+ years experience in healthcare auditing

Job description

ESSENTIAL FUNCTIONS

• 1. Apply structured auditing criteria to abstract medical records, and accurately enter the results of chart audits into the healthplans database.
• 2. Abstract medical record documentation submitted for HEDIS measures, used annually for reporting to National Committee for Quality Assurance (NCQA). The HEDIS measures are used to assist in measuring quality of health care provided to healthplan members.
• 3. Maintains productivity level with less than a 5% error rate in record abstraction and data entry on an ongoing basis.
• 4. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• 5. Maintain complete confidentiality of company related business.
• 6. Maintain effective communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS

• Registered Nurse (RN) with unrestricted license in state or Licensed Practical Nurse.
• 3+ years relevant experience.
• Experience in utilization review, quality assurance, and/or medical record and site review audits.
• Knowledge of medical terminology standard medical practices, formal quality improvement process, and federal, state, accreditation regulations and standards.
• Verbal and written communications skills .
• PC proficiency to include Word and Excel.
• Active LPN or RN License. HEDIS Abstraction experience

PREFERRED JOB REQUIREMENTS

• HEDIS abstracting clinical information experience.