Clinical Auditor: Appeals and Grievances
HealthfirstRemote
Posted December 9, 2024
81099 - 116480 USD
Full Time
About the Company
Healthfirst believes that every New Yorker deserves access to the best available healthcare. As one of New York’s highest quality not-for-profit health insurers serving close to two million New Yorkers, we make this a reality for our members. Founded more than 30 years ago by the leading hospital systems in downstate New York, Healthfirst established a partnership model that enables hospitals, health systems, and physicians in our network to prioritize health outcomes over profits, placing the needs of our members and community first. Healthfirst serves members in New York City, on Long Island, and in Westchester, Rockland, Sullivan, and Orange counties, offering market-leading products to suit every life stage. Our offerings include Medicaid plans, Medicare Advantage plans, Child Health Plus plans, Essential Plans, Long-Term Care plans, and Qualified Health plans. For more information on Healthfirst, please visit healthfirst.org.
Job Description
The Clinical Auditor performs audit functions for Healthfirst clinical teams to determine operational efficiency, adherence to regulatory requirements, and achievement of quality standards. The audits may include reviewing case management and utilization review decision-making.
Requirements
- Maintains tracking tools to log audit results
- Assists with evaluating and analyzing aggregate quality performance data
- Develops strategies for business performance improvement initiatives
- Assists with creating and revising audit tools
- Applies clinical and critical thinking skills to evaluate the quality and effectiveness of case management and/or utilization review decision-making
Benefits
- Medical, dental and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
