Quality Improvement Auditor (Clinical)

Position Title : Quality Improvement Auditor (Clinical)

Work Location : Remote

Assignment Duration : 04 months

Work Arrangement : 08 : 00am / 5 : 00pm AZ time, with 1 hour lunch, Mon - Fri. (There may be instances of required OT when approved by management)

Position Summary :

Lead medical record audits, monitor and analyze clinical documentation, and modify business processes to measure member outcomes. Assess provider performance and quality of care through clinical case reviews.

Key Responsibilities :

• RN or LPN / LVN will review medical records to determine if they meet predetermined requirements / standards for HEDIS measures and collect associated data. Previous HEDIS experience preferred.
• Individuals will review between 50-100 records per 8-hour day (based on HEDIS measures reviewed) with 95% or better accuracy.

Lead case reviews to assess the clinical performance provided in the provider network, including written clinical summaries and recommendations

Perform ongoing quantitative and statistical analysis of the business unit's performance data to include various contracted performance measures, service utilization and member / provider complaint and quality of care trends

Coordinate with internal teams to assure audit requests are fully understood, accurately compiled and delivered timely

Perform other performance and process improvement activities. Performs other duties as assigned

Education / Certification

Required : Bachelor's degree in nursing, related field or equivalent experience and requires an clinical license

Preferred : Licensure

Required : RN, LVN, LPN License

Preferred : Licensure

Must haves : HEDIS Experience Preferred

Nice to haves : Previous Quality Experience, Previous Auditing Experience

Disqualifiers :

Performance indicators :

Knowledge of HEDIS Hybrid Measures

Ability to utilize technology proficiently (TEAMS, Excel, EMR's, QMRM)

Ability to stay organized and meet deadlines