Quality Review Auditor - MJHS : Job Details

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Quality Review Auditor (QRA) is responsible for ongoing audits of the care management staff, quality assurance, accuracy and overall integrity of the care management records and documentation. QRA will listen to the calls completed by the care management staff to identify gaps in knowledge and assess for professionalism of the staff completing the calls. This role is to ensure compliance with NYS DOH and CMS regulations through development of audit tools and validating all data collected. Quality Review Auditor will be responsible to analyze collected audit data, identify trends for staff re-training and implementing corrective action plans in collaboration with Coordinated Care Management staff. Provide support to Directors, Managers and Supervisors to ensure that all documentation and reporting requirements are prepared and maintained in a professional and well-coordinated manner.

• Graduate from an accredited School of Nursing. BSN or BS degree preferred
• Minimum of two (2) years of working in care management experience required
• Managed Care experience preferred
• Licensed to practice as Registered Professional Nurse in NYS
• Excellent analytical skills, interpretation of data
• Strong critical thinking skills
• Knowledge of Medicare and Medicaid regulations
• Ability to set priorities and to handle multiple assignments
• Working knowledge of audit techniques and methodologies
• Working knowledge of State and Federal regulations
• Travels to perform business partners training