Clinical Auditor – Appeals and Grievances
Job Description:
• performs audit functions for Healthfirst clinical teams and vendors
• maintains tracking tools to log audit results
• assists with evaluating and analyzing aggregate quality performance data
• develops strategies for business performance improvement initiatives
• assists with creating and revising audit tools
• applies clinical and critical thinking skills to evaluate quality and effectiveness of case management
Requirements:
• NYS LPN or RN license
• unexpired NYS driver's license or NYS ID (if residing outside of NYS, must obtain a NYS ID before employment)
• relevant previous work experience (e.g. medical records review; claims processing; utilization/case management)
• knowledge of Department of Health (DOH) and Local Department of Social Services and CMS regulations
• nursing experience in acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA)
• experience with systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, EMR, MACESS
• language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
• intermediate Microsoft Word, Excel, and Outlook skills
• time management, critical/creative thinking, project management, communication, and problem-solving skills
Benefits:
• medical
• dental
• vision coverage
• incentive and recognition programs
• life insurance
• 401k contributions
Apply Now
Apply Now
• performs audit functions for Healthfirst clinical teams and vendors
• maintains tracking tools to log audit results
• assists with evaluating and analyzing aggregate quality performance data
• develops strategies for business performance improvement initiatives
• assists with creating and revising audit tools
• applies clinical and critical thinking skills to evaluate quality and effectiveness of case management
Requirements:
• NYS LPN or RN license
• unexpired NYS driver's license or NYS ID (if residing outside of NYS, must obtain a NYS ID before employment)
• relevant previous work experience (e.g. medical records review; claims processing; utilization/case management)
• knowledge of Department of Health (DOH) and Local Department of Social Services and CMS regulations
• nursing experience in acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA)
• experience with systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, EMR, MACESS
• language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
• intermediate Microsoft Word, Excel, and Outlook skills
• time management, critical/creative thinking, project management, communication, and problem-solving skills
Benefits:
• medical
• dental
• vision coverage
• incentive and recognition programs
• life insurance
• 401k contributions
Apply Now
Apply Now