HEDIS Nurse Quality Auditor (RN-LPN)

Company Overview

Mirra Health Care and CSTS Customer Service and Technology Solutions LLC are leading third-party administrators dedicated to enhancing the healthcare experience through efficient claims processing and compliance with federal regulations. Our mission is to transform how healthcare is accessed and delivered by providing exceptional products and services to our partners.

Position Summary:

TThe Nurse Auditor will coordinate and oversee the Health Plan HEDIS audits. Perform routine auditing of medical records and other clinical functions in the Quality department

Knowledge/Skills/Abilities:

· May perform non-clinical system and process audits, as needed.

· Assesses clinical staff regarding appropriate decision-making.

· Reports daily outcomes, identifies areas of re-training for staff, and communicates findings to leadership.

· Ensures auditing approaches follow a health plan standard in approach and tool use.

· Assists in preparation for regulatory audits by performing file review and preparation.

· Participates in regulatory audits as subject matter expert and fulfilling different audit team roles as required by management.

· Maintains member/provider confidentiality in compliance with the Health Insurance Portability and Accountability Act (HIPAA) and professionalism with all communications.

· Adheres to departmental standards, policies, protocols.

· Maintains detailed records of auditing results.

· Assists with developing training materials or job aids as needed to address findings in audit results.

· Meets minimum production standards.

· May conduct staff trainings as needed.

Duties:

1) Administers a universal training curriculum for new employees, as well as ongoing training to maintain identified core competencies.

2) Develops and updates training curriculum based on clinical staff knowledge, needs, and areas of improvement needed as identified based on audit scores by senior leadership, staff request, or other business indicators and disseminate to staff as needed.

3) Understand cross-functional team processes to identify and solve system issues.

4) Participates in development, testing and implementation of new programs and systems.

5) Evaluates effectiveness of training tools in accordance with CMS requirements.

6) Completes routine audits in accordance with meeting contractual requirements and communicate results to respective managers, identify gaps in reporting and implement improvements.

7) Prepares audit findings, documentation of deficiencies and communicates to manager.

8) Facilitates a response mechanism to individuals/teams for questions/concerns.

9) Reviews and recommends updates to policies and procedures within the Quality Department

10) Responsible for staying abreast of product/member/provider issues, legislation, CMS mandates, policy changes and system changes so they can be considered for training topics.

11) Reviews policies at least annually ensuring policies meet CMS standards.
Updates departmental policy to meet delegation requirements.

12) Works alongside the Management staff of delegated teams to ensure policy is properly trained and operationalized.

13) Responsible for monitoring and reporting compliance issues.

14) Monitoring includes ongoing audits, improvement actions and overall oversight or required audits.

15) Demonstrates understanding necessary to assess, review and apply criteria from Medicare Guidelines, CMS criteria, medical policy, and health plan specific criteria.

16) Provides regular follow-up with delegates for completion of corrective action plans and improvement action plans.

17) Submits reports/audits timely according to health plan requirements.

18) Analyze results, provide interpretation, and identify areas for improvement.

19) Schedule maintained to ensure specific training and activities are documented for submission as evidence, etc.

20) Serves as Subject Matter Expert (SME) for less experienced team members and internal partners. Coordinates and participates in the Quality Initiative (QI) Meeting and other meetings as assigned.

21) Supports Health plan goals by actively participating in orientation, training programs, task forces, project teams and other special endeavors.

22) Maintains strictest member and company confidentiality; ensures member health information is secured each day; HIPAA knowledge and focus.

23) Able to work efficiently under pressure.

24) Performs other duties as assigned.

Qualifications:

Education: RN or LPN

Licensure: Active and unrestricted Registered Nurse (RN) or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) license required in Illinois, Colorado, and Georgia.

· Colorado and Georgia licensure can be covered under a compact licensure or separate license for each state.

· Licensure is needed in all 3 states

· Candidate must reside in Florida

Experience: RN or LPN with 3-5 years’ experience in Managed Care preferred, knowledge of CMS standards, NCQA standards, and knowledge of HEDIS and Star Ratings. Experience with audits, writing policies and procedures, gathering evidence to demonstrate compliance is required. Must be able to use basic office equipment. Knowledge of ICD-10 and CPT-4 coding, medical terminology helpful. Must demonstrate strong verbal and written communication skills.

· Critical Thinking — Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.

· Excellent Communication Skills, both verbal and written

· Judgment and Decision Making — Considering the relative costs and benefits of potential actions to choose the most appropriate one.

· Writing — Communicating effectively in writing as appropriate for the needs of the audience.

· Complex Problem Solving — Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

· Proven ability to work creatively and analytically in a problem-solving environment demonstrating teamwork, innovation, and excellence.

· Computer Skills: Knowledge of Word Processing software, database software, spreadsheet and Internet software.

· Physical Demands: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.

If you are passionate about improving healthcare delivery and ready to take on a leadership role, we invite you to apply today and help us make a difference!

Job Type: Full-time

Pay: $75,000.00 - $80,000.00 per year

Benefits:
• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:
• 8 hour shift
• Day shift
• Monday to Friday
• Weekends as needed

Application Question(s):
• Do you have or can you obtain an active and unrestricted Registered Nurse (RN) or Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) license required in Illinois, Colorado, and Georgia.

Location:
• Florida (Preferred)

Work Location: Remote

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