Quality Auditor II - RN

Responsible for the quality review of claims to enhance the clinical, network, and case management services. Also responsible for coordinating all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs and medical consultant services.

Duties:

Creates and maintains medical consultant calendar to ensure daily coverage.

Performs audits on claims and correspondence to determine the accuracy and completeness of the physician network and medical consultants.  

Maintains records and prepares reports on quality audit results. Quality results include accuracy rates, turnaround times, denial rates, error trends and operational effectiveness.

Evaluates quality audit procedures, including quality scorecards, matrixes, audit point sheets and trending for the Physician Excellence and Medical Consultant Program.

Responds to internal/external clinical customer complaints/appeals within established department guidelines.

Responsible for verification of all professional licenses for RN & medical consulting staff.

Analyze, prepare, and distribute quarterly audit outcomes including error trends, to the Business Unit Directors.

Primary responsibility for documentation of CMS-CAPs results in SharePoint database

Conduct ad hoc file audits against business process flows when new business practices are set in place to monitor adherence to Process Flow as it relates to regulatory compliance.

Must be proficient in MS Office products (Word, Excel, Outlook and PowerPoint)