Clinical Auditor: Appeals and Grievances

The Clinical Auditor performs audit functions for Healthfirst clinical teams (e.g., Care Management, Reassessment/Clinical Eligibility, Utilization Management, etc.) and delegated vendors and partners within internal time frames and deadlines to determine operational efficiency, adherence to regulatory requirements, and achievement of quality standards.

• Perform audit functions to determine operational efficiency, adherence to regulatory requirements, and achievement of quality standards.
• Conduct audits that may include but are not limited to listening to Care Manager phone calls; reviewing Uniform Assessment System (UAS) assessments, care plans, medical authorizations, and supporting documentation to ensure compliance with regulatory requirements and internal policy.
• Maintain tracking tools to log audit results, identify areas of non-compliance, and determine areas of improvement for discussion with management and/or at departmental team meetings.
• Assist with evaluating and analyzing aggregate quality performance data.
• Develop strategies for business performance improvement initiatives, including identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports.
• Assist with creating and revising audit tools to ensure audits and reports are value-added.
• Apply clinical and critical thinking skills to evaluate the quality and effectiveness of case management and/or utilization review decision-making.
• Perform additional duties as assigned.

• NYS LPN or RN license.
• Unexpired NYS driver's license or NYS  residing outside of NYS, must obtain NYS e commencement of employment.

• Relevant previous work experience such as medical records review; claims processing; utilization/case management in a clinical practice or managed care organization; managed care plan products (e.g., Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Local Department of Social Services and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care; nursing experience in an acute, sub‑acute or long‑term care (LTC) setting or managed long‑term care plan (MLTCP, FIDA);
  Geriatrics, Medical Surgical Nursing, Case Management or Discharge Planning.
• Experience working with systems:
  Care Enhance Clinical Management Software (CCMS), True Care, PEGA, Citrix, Right Fax, VoIP, virtual work platforms (VPN), Electronic Medical Record (EMR) database containing patient health information (PHI), and/or MACESS archival system.
• Language preferences:
  Spanish, Russian, French, Creole, Mandarin, Cantonese.
• Intermediate Microsoft Word, Excel, and Outlook skills.
• Ability to build and maintain positive relationships with cross‑functional teams and interact with all levels of management.
• Strong time management, critical/creative thinking, project management, communication, and problem‑solving skills.

Salary range:
Greater New York City Area (NY, NJ, CT residents): $81,099 – $116,480. All other locations (within approved locations): $71,594 – $106,080. Salary and related compensation are contingent on work experience, education, licenses and certifications, and other factors. Benefits include medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401(k) contributions (all benefits are subject to eligibility requirements).

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers or calling .

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