Clinical Auditor: Appeals and Grievances

Description and Requirements

The Appeals and Grievances Clinical Quality Auditor performs audit functions for Healthfirst within internal timeframes and deadlines to determine operational efficiency, adherence to regulatory requirements, and achievement of quality standards. The audits may include but are not limited evaluating and ensuring compliance with internal and regulatory standards for appeals and grievances, outlining audit findings, recommending corrective actions, and effectively communicating the findings.

Duties and Responsibilities:

• Conduct quality audits of A&G items cases grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including job aids, regulatory requirements, and case documentation including eligibility, claims, authorizations, faxes, and any additional information required to complete the audit.
• Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
• Review clinical documentation for accuracy, completeness identifying any discrepancies or non-compliance issues
• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.
• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
• Maintains tracking tools to log audit results including areas of non-compliance and informing what areas of improvement are needed for discussion with management and/or at departmental team meetings
• Assists with evaluating and analyzing aggregate quality performance data
• Apply clinical and critical thinking skills to evaluate the quality and effectiveness of appeals and grievances determinations
• Additional duties as assigned

• LPN or RN license
• 1+ years of Appeals and Grievances experience
• HS Diploma or GED from an Accredited Institution

• Previous work experience in Appeals and Grievances in managed care plan products (e.g. Medicaid, Medicare, Commercial) and knowledge of Department of Health (DOH) and Center for Medicare & Medicaid Services (CMS) regulations pertaining to managed care
• Experience working with any of the following systems: TruCare, PEGA, Citrix, RightFax, Virtual work platforms (VPN), MHS, Salesforce, OnBase
• 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.
• Time management, critical/creative thinking, communication, attention to detail, problem-solving skills knowledge of regulatory framework and understanding of clinical practices