Clinical Quality Auditor

Job Title

As part of the overall clinical audit process, assess and audit medical record charts to ensure compliance with internal (EmblemHealth) and external regulatory and accreditation requirements. Compare collected data against Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Assurance Reporting Requirements (QARR) audit standards. The information abstracted from completed chart review will directly impact EmblemHealth's Quality award programs, including Medicare Stars and Quality Incentive Awards. Identify and report significant and/or patterns of variances from established standards that can negatively impact scores. May provide process improvement recommendations to safeguard a high quality of clinical care for patients.

Responsibilities

• Support EmblemHealth's Quality program by conducting targeted chart review to enhance quality scores during the annual Medical Record Review project as well as throughout the year for Supplemental data collection.
• Review each chart to determine if the patient meets the selection criteria.
• Complete one audit tool (paper form or row in the electronic spreadsheet) for each patient that meets the criteria.
• Ensure that patient confidentiality is protected.
• Utilize appropriate tools, processes, standards, and techniques to perform audits.
• Identify variations from established standards in audit results.
• Ensure that these variations are reported accurately and timely.
• May provide assistance in the compilation/interpretation of data and results.
• Conduct telephonic outreach calls to EmblemHealth Members in support of various HEDIS/QARR measures, to complete health assessments, and collect historical information that directly impacts Quality results.
• Ensure that relevant areas of patient care are covered so that a complete picture can be reported on (i.e., accessibility of care, communication with providers, care coordination, interactions with staff).
• Provide recommendations on process improvements based on audit results.
• Perform other duties/tasks as required or directed.

Qualifications

• Bachelors' Degree.
• Current licensed NP, LPN or RN with 3 - 5years of clinical experience in critical care or med-surgical experienced (Required)
• 3 5 years of relevant, professional work experience (Required)
• 2 3 years' experience in a managed care environment (Preferred)
• Knowledge of HEDIS/QARR/Star specifications (Required)
• Proven track record of accurately performing audits within specified parameters of quality and timeliness (Required)
• Advanced clinical assessment skills and the ability to apply clinical criteria and guidelines (Required)
• Attention to detail, and the ability to proficiently read and interpret medical records (Required)
• Experience with EPIC (Preferred)
• Knowledge of ICD-10 codes (Required)
• Excellent communication skills - verbal, written, interpersonal (Required)
• Must have ability to physically travel between sites (Required)