Jefferson Health Plans is committed to the development of its staff and the achievement of their career goals. We are hiring a Quality Management Auditor to join our team! We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.
While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.
Working under minimal supervision, conduct medical record reviews for the purpose of credentialing, re-credentialing, or ongoing monitoring for providers on a corrective action plan (CAP).
As the Quality Management Auditor, your daily duties may include:

• Conduct medical record review for compliance with medical record keeping and preventive standards.
• Complete assignments to ensure providers have a valid audit every two years.
• Communicate results (including failed audits and required CAPs) to the appropriate departments/individuals within established timeframes.
• Ensure CAP audits are scheduled and completed within required timeframes.
• Send audit results to office for review. Review audit results with practitioners and site staff if identified as needing improvement. Serve as resource to practitioner and staff as needed
• Yearly review of preventive care guidelines and audit tools.
• Review audit findings with Medical Director for corrective action as warranted and according to policy and procedure.
• Update internal software with audit findings. Maintain accuracy and timeliness in database management.
• Collaborate with Provider Relations staff for timely completion of audits and provider profiles for re-credentialing purposes

Qualifications:

• Graduate of accredited school of nursing, RN,
• 2 years of experience in quality management monitoring activities and/or credentialing/ recredentialing reviews.
• Development, implementation, and evaluation of quality management activities in acute and/or ambulatory health care settings.
• Managed care experience preferred.

Skills, We Value

• Excellent verbal and written communication skills.
• Ability to present and discuss clinical quality of care issues with Management and Medical Director.
• Strong analytical and critical thinking skills.
• Strong organizational skills and ability to manage multiple priorities.
• Knowledge of NCQA standards preferred.
• Ability to function independently with minimal supervision.
• Valid driver’s license and insurance.
• Ability to travel (to and from office sites), as needed. Moderate walking required.
• Lift/push/pull/hold/carry up to 10 pounds.
• Intermediate level computer skills in Microsoft Office, SharePoint and Teams preferred.