Clinical Auditor – Appeals and Grievances

Job Description:

  • performs audit functions for Healthfirst clinical teams and vendors
  • maintains tracking tools to log audit results
  • assists with evaluating and analyzing aggregate quality performance data
  • develops strategies for business performance improvement initiatives
  • assists with creating and revising audit tools
  • applies clinical and critical thinking skills to evaluate quality and effectiveness of case management

Requirements:

  • NYS LPN or RN license
  • unexpired NYS driver's license or NYS ID (if residing outside of NYS, must obtain a NYS ID before employment)
  • relevant previous work experience (e.g. medical records review; claims processing; utilization/case management)
  • knowledge of Department of Health (DOH) and Local Department of Social Services and CMS regulations
  • nursing experience in acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA)
  • experience with systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, EMR, MACESS
  • language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
  • intermediate Microsoft Word, Excel, and Outlook skills
  • time management, critical/creative thinking, project management, communication, and problem-solving skills

Benefits:

  • medical
  • dental
  • vision coverage
  • incentive and recognition programs
  • life insurance
  • 401k contributions
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