Quality Review Auditor

The challenges of affordable healthcare continue to create new opportunities. Elderplan and Home First, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

This position is responsible for assuring high quality performance, effectiveness and adherence to internal guidelines and process in compliance with Federal and State regulatory requirements. The scope of responsibility is for clinical initiatives coordinated and overseen by Medical Affairs Administration and key quality/compliance indicators for the A&G Department. This is accomplished by developing monitoring and auditing tools to review performance, evaluate effectiveness, identify trends and collaborate with business leads to recommend performance enhancements.

Prepares findings and reports on outcomes for both internal and external clinical initiatives. Collaborates with all internal business leads and externally with participating providers of services. Working in collaboration with A&G Director, audits to identify areas for performance improvement within staff and/or with system enhancements. Provides system training for newly hired A&G staff and updates all when system upgrades are implemented.

• Bachelor's Degree preferred
• Minimum of three years Health Plan experience with one to two years focus on Customer Service, Compliance, A&G, UM, CM or Quality Management
• Knowledge of federal and state Medicare and Medicaid regulatory requirements for Managed Care
• Proficient in Excel, Access, Power Point, Microsoft Office
• Knowledge of membership, claim, and care management systems
• Skilled in record and data review
• Excellent writing skills
• Excellent interpersonal communication skills
• Excellent organizational skills