Less than 5 years experience • Managed Care & Health Insurance
Prefers RN's with HEDIS experience. 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.
- Conducts on-site reviews at participating provider offices to assess environment, quality of physicians medical records, and compliance with documentation standards.
- Prepares appropriate documentation to summarize on-site findings with physician, providing education and discussing opportunities for improvement.
- Assists the Quality Management department with various special projects and focused clinical studies.
- Responsible for analysis of audit findings.
- Produces various reports as requested.
- Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate.
- Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.
- Co-ordinates and manages the Corrective Action Plan (CAP) process for assigned audit type
- Conducts reaudits ensuring prior deficiencies were addressed.
- Three to five years related business experience, preferably health care industry.
- Requires Registered Nurse (RN) active New Jersey License.
- Knowledge of managed care principles, medical terminology, use PC's and related software.
- Knowledge of URAC accreditation standards and HEDIS principles.
- Knowledge of case/care management principles and utilization management.