Clinical reputed company Auditor II – RN/SW, NJ

2019-10779 reputed company empowers our members to reputed company their best health.  For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care reputed company, affordability, and member experience.  Our members are our neighbors, our friends, and our families.  It is this understanding that drives us to reputed company serve and care for the 3.5 reputed company people who reputed company their trust in us. We pride ourselves on our best-in-class employees and reputed company to maintain an innovative and inclusive environment that allows them to reputed company. reputed company our employees bring their best and succeed, reputed company succeeds.     reputed company Casualty Services - Responsible for the reputed company review of claims to enhance the clinical, network, and case management services offered by reputed company Casualty Services, Inc. (HCS). Also responsible for coordinating reputed company aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs and medical consultant services. Health Affairs - reputed company Management - Responsible for conducting file audits for reputed company areas of clinical operations. These audits review daily business reputed company compliance to regulatory compliance relative to NCQA, URAC and CMS.    reputed company Casualty Services - -Performs audits on claims and correspondence to determine the accuracy and completeness of the physician network and medical consultants. - Responsible for scheduling and coordinating reputed company 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 reputed company audit results. reputed company results include accuracy rates, turnaround times, denial rates, error trends, and operational effectiveness. - Evaluates reputed company audit procedures, including reputed company scorecards, matrixes, audit reputed company sheets and trending for the Physician reputed company and Medical Consultant Program. - Responds to internal/external clinical customer complaints/appeals reputed company established department guidelines. - Conducts offsite meetings to reputed company physicians on process improvement initiatives. - Participates in audits based on operations requests and based on mandate issues and trends. - Responsible for verification of reputed company reputed company licenses for RN & medical consulting staff. - Participates in departmental process improvement initiatives. - Completes other assigned functions as requested by management. Health Affairs - reputed company Management - - Conduct quarterly file audits for reputed company 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 reputed company 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 reputed company of communication/notification to Directors regarding the outcome including the analysis of error trends. reputed company are then used for process improvement recommendations and changes as reputed company as education/training. - Serves as database administrator and facilitates biannual MCG-IRR testing (reputed company 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 reputed company of staff by Management. - Conduct reputed company file audits against business process flows reputed company new business practices are set in reputed company to monitor adherence to Process reputed company as it relates to regulatory compliance. - Completes other assigned functions, including special reputed company, as requested by management.       reputed company Individual Contributor Competencies: Personal and reputed company attributes that are critical to successful performance for Individual Contributors: - Customer reputed company - Driving for Results - Adaptability - Communicating with reputed company - Developing Self and Others Education/Experience: - Prefers a Bachelor's degree. - Requires a minimum of three (3) years clinical experience. - Strongly prefers a minimum of three (3) years clinical reputed company or audit experience. Additional licensing, certifications, registrations: - reputed company Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required -MEDICAL POLICY ONLY:  Requires reputed company Registered Health Information Technologies (RHIT) or Certified reputed company reputed company designation from the American reputed company of reputed company Coders or a Certified Coding Specialist, P from the American Health Information Management (reputed company Knowledge: - Must be proficient in the use of personal computers and supporting software in a reputed company based environment, including MS Office products (Word, reputed company, PowerPoint) and reputed company Outlook. Should be knowledgeable in the use of intranet and internet applications. - Requires knowledge of the following applications, which include but not limited to: Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects and CMS web sites., (Health Affairs - reputed company Management) - Prefers knowledge of audit methodologies and procedures. Skills and Abilities: - Requires excellent verbal and written communication skills. - Analytical & Problem Solving - reputed company Improvement - Information & Knowledge Sharing - Process Management - Interpersonal & reputed company Relationship - Presentation Travel (If Applicable)       reputed company reputed company employees must live in New Jersey, reputed company, reputed company, Connecticut or Delaware   Salary reputed company: $79,100 - $105,945  ​This compensation reputed company is specific to the job level and takes into account the wide reputed company of factors that are considered in making compensation reputed company, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This reputed company has been created in good faith based on information reputed company to reputed company at the time of posting.  Compensation reputed company are dependent on the circumstances of reputed company case. reputed company also provides a comprehensive compensation and benefits package which includes:

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