Utilization Reviewer

Job Description

Job Description

Remote but must be able to get to Newark, Nj to pick up and drop off equipment
This position is responsible for conducting quality audits for state audits, HEDIS and quality referral and complaints issues. This position is also responsible for preparing weekly, monthly, quarterly and year-end reports.

Responsibilities:
1. Conducts on-site/virtual reviews at participating provider offices to assess environment, quality of physicians medical records, and compliance with documentation standards.
2. Prepares appropriate documentation to summarize on-site findings with physician, providing education and discussing opportunities for improvement.
3. Provides data support services to facilitate the process and analyze trends/patterns for quality improvement and health management.
4. Assists the Quality Management department with various special projects and focused clinical studies.
5. Performs related tasks or special studies as requested.
6. Assists in training of internal Horizon NJ Health staff, providers and vendors on programs and audit standards, both on and off site.
7. In-house representative and project lead for state audits.
8. Responsible for analysis of audit findings.
9. Produces various reports as requested.
10. Co-ordinates and manages the Corrective Action Plan (CAP) process for assigned audit type
11. Conducts reaudits ensuring prior deficiencies were addressed

1. Requires three to five years related business experience, preferably n health care industry.
2. Requires License Practical Nurse License or an active New Jersey Registered Nurse License.

1. Requires knowledge of managed care principles.
2. Requires knowledge of medical terminology.
3. Requires knowledge of PC's and related software.
4. Prefers knowledge of URAC accreditation standards and HEDIS principles.
5. Prefers knowledge of health management or patient education.