Responsible for conducting file audits for all areas of clinical operations. These audits review daily business practice compliance to regulatory compliance relative to NCQA, URAC and CMS.

Responsibilities:

Conduct quarterly file audits for all 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 outcomes 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 generation of communication/notification to Directors regarding the outcome including the analysis of error trends. Outcomes are then used for process improvement recommendations and changes as well as education/training.Serves as database administrator and facilitates biannual MCG-IRR testing (Milliman 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 up education of staff by Management.Conduct ad hoc file audits against business process flows when new business practices are set in place to monitor adherence to Process Flow as it relates to regulatory compliance.Completes other assigned functions, including special projects, as requested by management.

Education/Experience:

Bachelor's degree preferredRequires a minimum of three (3) years clinical experience.Strongly prefers a minimum of three (3) years clinical quality or audit experience.

Additional licensing, certifications, registrations:

Active Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required

Knowledge:

Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft 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.Knowledge of HEDIS measures and specifications strongly preferred.

Skills and Abilities:

Requires excellent verbal and written communication skills.Analytical & Problem SolvingContinuous ImprovementInformation & Knowledge SharingProcess ManagementInterpersonal & Client RelationshipPresentationPrefers knowledge of audit methodologies and procedures.

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range:

$77,900 - $104,370

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity.  This range has been created in good faith based on information known to Horizon at the time of posting.  Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes:

Comprehensive health benefits (Medical/Dental/Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.  Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.