Quality Auditor II

About the Role Health Affairs - Quality Management - Responsible for conducting file audits for all areas of clinical operations. These audits review daily business practice compliance to regulatory compliance relative to NCQA, URAC and CMS. What You'll Do Conduct quarterly file audits for all lines of business against business Process Flows to determine compliance with regulatory standards according to NCQA, URAC and CMS. Analyze, prepare and distribute quarterly audit outcomes including error trends to the Business Unit Directors. Conduct monthly CMS‑CAPs audits against business Process Flows in order to evaluate compliance with Medicare standards. Document CMS‑CAPs results in SharePoint database and generate communication/notification to Directors regarding the outcome including the analysis of error trends; use outcomes for process improvement recommendations and changes as well as education/training. Serve as database administrator and facilitate biannual MCG‑IRR testing (Milliman Care Guidelines—Inter Rater Reliability) administered to clinical and medical director staff. Notify testing dates to staff, analyze final reports, and submit reports to functional unit Directors and Medical Management Committee for follow‑up education by Management. 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. Complete other assigned functions, including special projects, as requested by management. What You Bring Core Individual Contributor Competencies Customer Focus Driving for Results Adaptability Communicating with Impact Developing Self and Others Education Education / Experience Prefers a Bachelor's degree. Requires a minimum of three (3) years clinical experience. Strongly prefers a minimum of three (3) years clinical quality or audit experience. Additional Licensing, Certifications, Registrations Active Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required. Medical policy only: Requires current Registered Health Information Technologies (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist, P from the American Health Information Management (AHIMA). Knowledge Proficient in personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook. Skilled in intranet and internet applications. Knowledge of Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects and CMS websites. Prefer knowledge of audit methodologies and procedures. Skills and Abilities Excellent verbal and written communication skills. Analytical & Problem Solving. Continuous Improvement. Information & Knowledge Sharing. Process Management. Interpersonal & Client Relationship. Presentation (travel if applicable). Compensation Salary Range: $79,100 - $105,945 Benefits Comprehensive health benefits (Medical/Dental/Vision) Retirement Plans Generous PTO Incentive Plans Wellness Programs Paid Volunteer Time Off Tuition Reimbursement Disclaimer Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. Equal Opportunity Employer Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process. #J-18808-Ljbffr