Company Statement

EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.

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Clinical Quality Auditor - Hybrid

🔍 New York, New York

New

💼: EmblemHealth

📅   : 16 hours ago Post Date

Summary of Job

As part of the overall clinical audit process, assess and audit medical record charts to ensure compliance with internal (EmblemHealth) and external regulatory and accreditation requirements. Compare collected data against Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Assurance Reporting Requirements (QARR) audit standards. The information abstracted from completed chart review will directly impact EmblemHealth’s Quality award programs, including Medicare Stars and Quality Incentive Awards. Identify and report significant and/or patterns of variances from established standards that can negatively impact scores. May provide process improvement recommendations to safeguard a high quality of clinical care for patients.

Responsibilities

Support EmblemHealth’s Quality program by conducting targeted chart review to enhance quality scores during the annual Medical Record Review project as well as throughout the year for Supplemental data collection.
Review each chart to determine if the patient meets the selection criteria.
Complete one audit tool (paper form or row in the electronic spreadsheet) for each patient that meets the criteria.
Ensure that patient confidentiality is protected.
Utilize appropriate tools, processes, standards, and techniques to perform audits.
Identify variations from established standards in audit results.
Ensure that these variations are reported accurately and timely.
May provide assistance in the compilation/interpretation of data and results.
Conduct telephonic outreach calls to EmblemHealth Members in support of various HEDIS/QARR measures, to complete health assessments, and collect historical information that directly impacts Quality results.
Ensure that relevant areas of patient care are covered so that a complete picture can be reported on (i.e., accessibility of care, communication with providers, care coordination, interactions with staff).
Provide recommendations on process improvements based on audit results.
Perform other duties/tasks as required or directed.

Qualifications

Bachelors’ Degree.
Current licensed NP, LPN or RN with 3 - 5years of clinical experience in critical care or med-surgical experienced (Required)
3 – 5 years of relevant, professional work experience (Required)
2 – 3 years’ experience in a managed care environment (Preferred)
Knowledge of HEDIS/QARR/Star specifications (Required)
Proven track record of accurately performing audits within specified parameters of quality and timeliness (Required)
Advanced clinical assessment skills and the ability to apply clinical criteria and guidelines (Required)
Attention to detail, and the ability to proficiently read and interpret medical records (Required)
Experience with EPIC (Preferred)
Knowledge of ICD-10 codes (Required)
Excellent communication skills - verbal, written, interpersonal (Required)
Must have ability to physically travel between sites (Required)

Security Disclosure

If you receive a job offer from EmblemHealth, the email will be from “HRTalentAcquisition” with the subject: “Offer of Employment for (job title) – Please respond online.” We will never ask you to join a Google Hangout, buy your own equipment, or pay to apply. We also do not use third-party email services like Yahoo or Gmail.

Pay Disclosure

At EmblemHealth, we prioritize transparency in our compensation practices. We provide a good faith estimate of the salary range for potential hires, which is based on key factors such as role responsibilities, candidate experience, education and training, internal equity, and market conditions. Please be aware that this estimate doesn’t account for geographic differences related to your work location. Typically, new hires may not start at the top of this range, as compensation is tailored to each individual's circumstances. For union positions, salaries will be determined according to the collective bargaining agreement. Join us at EmblemHealth, where your contributions are valued and supported by fair compensation.

EEOC Statement

We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship status, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.

Sponsorship Statement

At EmblemHealth, we are committed to building a diverse and talented workforce. However, we are unable to consider applicants who require, or are likely to require, either before or after hire, visa sponsorship for work authorization in the United States, including but not limited to H-1B, F-1 (STEM OPT), TN, or any other non-immigrant status. Some extremely rare exceptions may apply based on critical business needs.