Healthfirst

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

 Minimum Qualifications:

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

 Preferred Qualifications:

• 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

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $67,205 - $95,680

• All Other Locations (within approved locations): $59,800 - $87,360

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. HF Management Services, LLC complies with all applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. HF Management Services, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.