Clinical - Quality Improvement Auditor (Clinical) - 210664

Below mentioned is the job description for your reference :

Job Title : Quality Improvement Auditor Clinical

Location : Remote (Georgia EST candidates only)

Shift : Standard 8 : 00 AM 5 : 00 PM EST (Mon Fri).

Assignment Duration : 12 Months (Potential FTE Conversion)

Position Overview :

We are seeking an experienced Quality Improvement Auditor Clinical to join our (Quality Improvement Department). The auditor will be responsible for conducting medical record audits, assessing provider performance, identifying quality of care concerns, and driving compliance with clinical guidelines and standards. This role is critical to ensuring members receive safe, effective, and high-quality care.

Key Responsibilities :

Lead medical record audits (remote and on-site) to evaluate provider compliance with clinical practice guidelines.

Review and score clinical records using approved audit tools.

Conduct Quality of Care (QOC) and Potential Quality of Care (PQOC) investigations, ensuring timely follow-up and documentation.

Collaborate with providers via phone, fax, email, and mail to obtain medical records for review.

Write clear, concise reports summarizing audit findings and recommendations.

Perform statistical and trend analysis on audit results, utilization data, and provider performance metrics.

Support process improvement initiatives, including policy / procedure updates and departmental collaboration.

Communicate with Medical Directors for review of specific cases requiring escalation.

Ensure compliance with Centene, Peach State Health Plan, and regulatory audit requirements.

Required Qualifications :

Education / Certification :

Bachelor's degree in Nursing or related field.

Active RN or LPN license in Georgia (or Compact License).

Experience :

Minimum 3+ years in nursing, quality improvement, auditing, or compliance.

Prior experience with medical record review, clinical audits, or PQOC / QOC investigations.

Strong writing / reporting experience with proven ability to draft concise clinical summaries.

Skills :

Medical record auditing, compliance, and investigation expertise.

Strong knowledge of clinical practice guidelines and care quality standards.

Proficiency with Microsoft Office Suite (Word, Excel, Outlook).

Excellent communication, critical thinking, and analytical skills.

Preferred Qualifications :

Prior experience with PQOC / QOC investigations, CPG audits, or administrative audits.

Familiarity with provider performance reporting and data analysis.

Experience in a managed care / health plan environment.

Work Schedule :

Training : 8 : 00 AM 5 : 00 PM EST (Mon Fri).

Post-training : Standard 8 : 00 AM 5 : 00 PM EST (Mon Fri).

No overtime expected.