Clinical Quality Auditor Lead (PS28390)

Employment Type

: Full-Time


: Accounting

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Your Talent. Our Vision. At Empire Blue Cross Blue Shield, a proud member of the Anthem, Inc. family of companies, it's a powerful combination, and the foundation upon which we're creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

This is an exceptional opportunity to do innovative work that means more to you and those we serve.

Clinical Quality Auditor Lead (PS28390)-RN preferred

Managed Long Term Care (MLTC)

Location: Office-Based NY, NY

Responsible for participating in clinical quality management activities that ensure programs meet accreditation and regulatory standards.

Primary duties may include, but are not limited to:

* Develops and oversees the Annual MLTC Quality Plan and any associated quality projects that are included as part of the plan.
* Prepares team for oversight audits. Prepares corrective action plans in response to oversight body's request.
* Conducts audits of Quality Management (QM) processes and files.
* Writes policies and procedures and assists with development of provider manuals, audit tools, and guidelines.
* Responsible for specific QM processes/ functions (i.e. compliance, grievances/appeals or HEDIS/quality improvement projects).
* Assists manager with day-to-day monitoring and prioritizing of workflows and activities.
* Develops and improves departmental processes and operations.
* Monitors goals, performance and processes.
* Assists with issues of non-compliance.
* Mentors and coaches staff.
* Trains new associates and re-trains current associate.
* Monitors and prioritizes workflows.
* Serves as a resource and a subject matter expert.

Preferred Experience:

? Prior MLTC experience

? Clinical experience-RN preferred

? Aggregation/interpretation of Data gathering

? Performance Improvement Project experience

? Knowledge of NCQA accreditation

? UAS experience

? Intermediate Excel proficiency

? Ability to travel may be required

Requires a BS in nursing, health sciences, health management or a related clinical field; 5 years of experience in utilization management, quality assurance and/or regulatory/accreditation standards/audits including 3 years of quality management experience; or any combination of education and experience, which would provide an equivalent background. o Current active unrestricted license as an RN, LCSW, LMSW, LMHC, LPC, LBA (as allowed by applicable state laws), LMFT, or clinical Psychologist, to practice as a health professional within the scope of licensure in applicable states or territory of the United States required. BSN and CPHQ (Certified Professional in Healthcare Quality) and prior project management experience is preferred. For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.

Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran.

Associated topics: business development, case management, development, liaison, manage, office manager, project, program development, project development, project management

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