Quality Auditor II

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years , we have been New Jersey's health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best‑in‑class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. 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 to evaluate compliance with Medicare standards. Document CMS‑CAPs results in a SharePoint database and generate communication to Directors regarding outcomes, including analysis of error trends. Outcomes support process improvement recommendations and 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, including maintenance, troubleshooting, notification of testing dates, analysis of final reports, and submission to functional unit Directors and the Medical Management Committee for staff education. Conduct ad hoc file audits against business process flows when new practices are introduced to monitor adherence to Process Flow and 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/Experience:

• Preferred: Bachelor’s degree.
• Minimum: 3 years clinical experience.
• Strongly preferred: 3 years clinical quality or audit experience.

Additional licensing, certifications, registrations:

• Active unrestricted NJ RN, LCSW, LMFT, LSW, or LPC license required.
• Medical policy positions required: current Registered Health Information Technology (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders, or Certified Coding Specialist, P from the American Health Information Management (AHIMA).

Knowledge:

• Proficient in Windows‑based personal computers and supporting software (MS Office, Outlook, intranet, internet applications).
• Familiar with Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects, and CMS websites.
• Preferred: knowledge of audit methodologies and procedures.

Skills and Abilities:

• Excellent verbal and written communication.
• Analytical & Problem Solving.
• Continuous Improvement.
• Information & Knowledge Sharing.
• Process Management.
• Interpersonal & Client Relationship.
• Presentation.

Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you! Salary Range: $79,100 - $105,945 Horizon also provides a comprehensive compensation and benefits package which includes: 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. This summary indicates the general nature and level of work performed by colleagues within this classification and is not intended as a comprehensive inventory of all duties, responsibilities, and qualifications required. 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 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 Horizon Blue Cross Blue Shield of New Jersey