Quality Management Auditor

Jefferson Health Plans • Jefferson Township, PA

2d

About The Position

Working under minimal supervision, schedule and conduct practitioner site audits for compliance with medical record, preventive care, access and availability and practice site standards for the purpose of credentialing and re-credentialing practitioners and ongoing monitoring

Requirements

• Specialized Diploma
• Graduate of accredited school of nursing, RN
• 2 years 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.
• Excellent verbal and written communication skills.
• Ability to present and discuss clinical quality of care issues with Management and Medical Director.
• Strong analytical and problem solving skills.
• Strong organizational skills and ability to manage multiple priorities.
• Ability to function independently with minimal supervision.
• Valid driver’s license and insurance.
• Ability to travel (to and from office sites), at least 70% of the time.
• Moderate walking required.
• Lift/push/pull/hold/carry up to 10 pounds.
• Basic understanding of QM principles.
• Basic computer skills in Outlook, MS Word, Excel and Access.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania

Nice To Haves

• Knowledge of NCQA standards preferred.
• Familiar with Philadelphia and surrounding areas, preferred.
• Basic computer skills in Outlook, MS Word, Excel and Access preferred.

Responsibilities

• Schedule and conduct practitioner site audits for compliance with medical record, preventive care, and practice site standards.
• Coordinate access and availability monitoring in conjunction with network management and the external vendor to ensure members access to care
• 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.
• Review audit results with practitioners and site staff at exit interview.
• Serve as resource to practitioner and staff for areas identified as needing improvement.
• Yearly review and update of changes for preventive care guidelines
• Review audit findings with Medical Director for corrective action as warranted and according to policy and procedure.
• Prepare documentation with QM 1 coordinator of case review for peer review activities and the Quality Management Committee.
• Update databases and spreadsheets with audit findings.
• Maintain accuracy and timeliness in database management.
• Collaborate with Provider Relations and Credentialing Department staff for timely completion of audits and provider profiles for re-credentialing purposes

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.
• For more benefits information, please click here
• In keeping with Jefferson's Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees.
• If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson.
• Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: Associate degree