Clinical Quality Auditor II - RN​/SW

Overview

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.

Horizon Casualty Services - Responsible for the quality review of claims to enhance the clinical, network, and case management services offered by Horizon Casualty Services, Inc. (HCS). Also responsible for coordinating all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs and medical consultant services. 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.

• Horizon Casualty Services - Performs audits on claims and correspondence to determine the accuracy and completeness of the physician network and medical consultants.
• Horizon Casualty Services - Responsible for scheduling and coordinating all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs.
• Creates and maintains medical consultant calendar to ensure daily coverage.
• Maintains records and prepares reports on quality audit results. Quality results include accuracy rates, turnaround times, denial rates, error trends, and operational effectiveness.
• Evaluates quality audit procedures, including quality scorecards, matrixes, audit point sheets and trending for the Physician Excellence and Medical Consultant Program.
• Responds to internal/external clinical customer complaints/appeals within established department guidelines.
• Conducts offsite meetings to educate physicians on process improvement initiatives.
• Participates in audits based on operations requests and based on mandate issues and trends.
• Responsible for verification of all professional licenses for RN & medical consulting staff.
• Participates in departmental process improvement initiatives.
• Completes other assigned functions as requested by management.

• 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.
• Primary responsibility for documentation of CMS-CAPs results in SharePoint database and generation of communication/notification to Directors regarding the outcome including the analysis of error trends. Outcomes are then used for process improvement recommendations and changes as well as education/training.
• Serves as database administrator and facilitates biannual MCG-IRR testing (Milliman Care Guidelines-Inter Rator Reliability) that is administered to clinical and medical director staff. This includes general maintenance and troubleshooting during entire testing period. Notification of testing dates to staff, analysis of final reports and submission of reports to functional unit Directors and Medical Management Committee for follow up education of staff 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.
• Completes other assigned functions, including special projects, as requested by management.

• Customer Focus
• Driving for Results
• Adaptability
• Communicating with Impact
• Developing Self and Others