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Quality Auditor (Nights)

Idemia North America
Chantilly, VA
IDEMIA is the global leader in identity and security. Our mission is to create a safe and simple future where identity verification is indisputable, and only you can assert your identity. We are a distributed company leveraging the latest technologies to deliver world-class products in the private and public sectors of finance, telecom, identity, security, retail, sports entertainment, commercial, government, and IoT. We use a variety of technologies and approaches to deliver quality product and services to government agencies and technology companies. IDEMIA is a made up of a group of 14,000 diverse people from different nationalities, speaking over 20 different languages. Together, our solutions impact the everyday lives of citizens and nations. In this ever-changing world, protecting your identity is paramount. Join the team that is ensuring one person- one identity.
BASIC FUNCTION AND RESPONSIBILITY

+ Ensures product quality is met according to predetermined procedures and that standards are followed.

+ Identifies and documents details of non-conformances for corrective actions.

+ Improves our Quality Management System (QMS).

ESSENTIAL DUTIES

+ Verify incoming and processed products with use of use calipers, templates, and other measuring tools to ensure that the products meet ANSI standards or client requirements.

+ Communicate non-conformities to appropriate levels of management.

+ Work independently in multiple areas.

+ Manage time to ensure turnaround and accuracy requirements are met.

+ Adhere to ISO 9000 specifications and requirements.

Required Skills:

+ The ability to understand and follow written and verbal instructions in English.

+ The attention to detail necessary to write QMS documentation.

+ Ability to handle multiple tasks.

+ Ability to work various hours.

+ Requires standing and walking, exerting up to 60lbs of lifting, carrying, pushing, pulling or otherwise moving objects.

+ Requires problem solving, negotiation and listening skills.

+ Ability to identify problems, collect data, establish facts, and draw valid conclusions.

+ Must be familiar with PC based MS Office applications.

Required Experience:

Minimum, High School Diploma or General Education Degree (GED).

Minimum of six months of work experience in a Quality or ISO controlled work environment.

Position is for PM Shift (5pm-5am) on a 3-4 bi-weekly rotation.

Work week schedule is Sunday-Wedneday OR Wednesday- Saturday with every other Wednesday off.

Requisition ID: 2021-3524

External Company URL: https://www.idemia.com

Street: 4250 Pleasant Valley

Telecommute: No

Security Access Level: Access 3: Eligible to work in the U.S

Work Schedule: Shift 3
10d ago

Clinical Quality Auditor (myNEXUS)

Anthem, Inc.
Reston, VA
SCHEDULE: Full-time

Your Talent. Our Vision. At my NEXUS, a proud member of the Anthem, Inc. family of companies, it's a powerful combination. It's the foundation upon which we're creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.

my NEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.

The Clinical Quality Auditor completes independent assessments of authorizations in accordance with my NEXUS policies and procedures, clinical guidelines, applicable regulatory standards and client requirements. This will ensure adherence to departmental and regulatory data integrity standards and requirements including contractual obligations with Health Plan Clients, State and Federal agencies and Center for Medicare & Medicaid Services (CMS). The Clinical Quality Auditor will support accreditation and general quality management initiatives, including but not limited to working closely with the Director of Quality Management and the Chief Clinical Officer to insure the company meets the standards for obtaining a URAC accreditation, and then subsequently works to insure the company continues to operate at such standards. The incumbent will assist with training new employees on the URAC standards and reinforce said standards with employees on an ongoing basis.
Duties/Responsibilities:

+ Independently use discretion and judgment to evaluate objective and subjective clinical documentation of member authorizations to assess performance of nursing skill and the skills of other allied health professionals, based on Business Unit expectations for performance

+ Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses and other allied health professionals

+ Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases

+ Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow my NEXUS policies, State regulations and Accreditation standards

+ Collate all data available to illustrate a full picture of an individual staff members performance (Work Force Management data, phone metrics, other)

+ Generate reports /findings of reviews for the Clinical Management Teams: in a clear, concise manner that is understandable and actionable

+ Provide consultation with Clinical Management leaders as requested to support staff coaching and development efforts

+ Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist my NEXUS employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and member engagement

+ Identifies tracks and records best practices, sharing the specifics with team leadership

+ Participate in training and performance improvement related projects to support staff development as well as assist with the training of new employees

+ The Clinical Quality Auditor will highlight key findings for implementation of performance improvement plans when necessary

+ Participate in URAC and NCQA accreditation activities

+ Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member documentation such as job aids and policies

+ Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings

+ Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings

+ Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served

+ Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner

+ Ability to work and interact with professionals as part of an interdisciplinary team

+ Self-motivated, flexible person who can flourish in an office setting with colleagues as well as in a self-structured independent setting

+ Ability to accept constructive feedback for continual improvement

+ Ability to add to a team atmosphere where a team approach is highlighted and valued

+ Thrives in a process based transactional work environment

+ Able to work independently; self-motivated with good organizational skills

+ Quickly adapt to new technology

+ Must stay abreast of all customer specific details, to ensure high quality customer service

+ Accept additional assignments willingly

Professional Responsibilities:

+ Excellent organizational, interpersonal, written and verbal communication skills

+ Maintains member confidentiality at all times

+ Capable to apply and conduct a logical approach to audits to arrive at fact-based recommendations based on source of truth documentation

+ Ability to remain a neutral party, negotiate, and drive to expected result

+ Follows all company policies related to time records

+ Has a passion for quality and performance improvement

+ Adheres to dress code, appearance is neat and clean

+ Completes annual education requirements in a timely fashion

+ Maintains confidentiality of employee, company and/or patient information at all times

+ Reports to work on time and from breaks as scheduled, completes work within designated time

+ Follows all company policies related to time records and time off policies

+ Attends staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested

+ Represents the organization in a positive and professional manner

+ Actively participates in performance improvement and continuous quality improvement (CQI) activities.

+ Complies with all organizational policies regarding compliance and ethical business practices

+ Communicates and demonstrates the mission, core values, ethics and goals of the Company, as well as the department

Required Skills/Abilities:

+ Excellent verbal and written communication skills

+ Excellent interpersonal and customer service skills

+ Excellent presentation skills

+ Excellent organizational skills and attention to detail

+ Excellent time management skills with a proven ability to meet deadline

+ Strong supervisory and leadership skills

+ Ability to prioritize tasks and to delegate them when appropriate

+ Ability to function well in a high-paced and at times stressful environment

+ Knowledge of healthcare payer and/or provider industry

+ Proficient with Microsoft Office Suite or related software

Education and Experience:

+ LPN, RN, PT, OT, PTA, or COTA license required

+ Experience preferred in Utilization Management

+ 2 or more years of clinical audit experience preferred

+ RN/LPN required in the state that you reside (must be active and unrestricted)

+ Ability to read and communicate effectively in English

+ Additional languages preferred

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For , is ranked as one of the 2020 World's Most Admired Companies among health insurers by Fortune magazine, and a 2020 America's Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

REQNUMBER: PS49976
60d+ ago

Auditor, Clinical Quality (DaVita IKC)

Davita
Remote
2000 16th St, Denver, Colorado, 80202, United States of America

DaVita Integrated Kidney Care (IKC) has proven that integrating care achieves the triple aim of improved patient quality of life, better outcomes and lower total cost of care. What sets DaVita IKC apart is that we not only provide great care management but we start with our heart with our patients and each other. We focus on creating both a great experience for our patients and a special place to work for our Clinical Quality Audit Specialist and teammates.

The Clinical Quality Audit Specialist performs internal audits as part of the DaVita Integrated Kidney Care (IKC) Quality and Patient Safety Program. These audits support the review but is not limited to the care provided, completeness of patient medical records, and the compliance with standards, policies, and procedures. The Clinical Quality Audit Specialist analyzes and reports outcomes at both a system and individual level and collaborates with operations team and other stakeholders to identify areas for continuous improvement. Additionally, the Clinical Quality Audit Specialist facilitates external quality oversight chart audits with health plans and CMS to ensure model of care requirements are met.

This is a Remote position.

Essential Duties and Responsibilities:

  • The Clinical Quality Audit Specialist prepares and performs internal and external quality audits, including but limited to, electronic and paper medical records, recordings, and live audits (Health plan/CMS)
  • Communicates and works with operations team and other stakeholders to resolve issues identified in the audit in a timely manner
  • The Clinical Quality Audit Specialist provides continuous quality improvement suggestions as part of the DaVita IKC Quality and Patient Safety Program based on audit and reporting findings
  • Participates in ad hoc or project-specific continuous quality improvement (CQI) initiatives
  • Supports DaVita IKC departments in design and implementation of quality audits
  • Assists in the development of quality policies and processes governing DaVita IKC operations as deemed necessary by leadership
  • Other duties as assigned.

Qualifications for the Clinical Quality Audit Specialist:

  • A.D.N degree from accredited school of nursing
  • B.S.N preferred; three-year diploma from accredited diploma program may be substituted for nursing degree
  • Minimum three (3) years' healthcare experience
  • Intermediate computer skills and proficiency in MS Word, Excel, Access, PowerPoint, and Outlook
  • Prior audit. Quality, or Patient Safety experience
  • Demonstrated expertise in disease management strongly preferred

DaVita as a Company:

DaVita Integrated Kidney Care (DaVita IKC) is the integrated care division of DaVita Inc. working on DaVita's vision to provide integrated care to all ESRD patients, who are some of the most medically complex and vulnerable patient populations in the US. Our more than 600 dedicated nurses, care coordinators, nurse practitioners (NPs), Clinical Quality Audit Specialists and business professionals integrate and manage care for more than 20,000 patients with late-stage chronic kidney disease (CKD) and end stage renal disease (ESRD) across the US each month.

DaVita IKC is on a mission to revolutionize kidney care, with a vision of making integrated care the standard of care for all renal patients. To help us achieve our vision, we're investing extensively in developing both our model of care and our team. When you join DaVita IKC as a Clinical Quality Audit Specialist, you're joining a compassionate team committed to quality patient care. Through our commitment to training, growth and quality we consistently achieve superior clinical outcomes while giving teammates the opportunity to excel in an award-winning environment that enables them to thrive both professionally and personally.

Join us as our Clinical Quality Audit Specialist as we pursue our vision "To Build the Greatest Healthcare Community the World has Ever Seen."

Why wait? Explore a career with DaVita today.

Go to http://careers.davita.com to learn more or apply.

What We'll Provide:

More than just pay to our Clinical Quality Audit Specialist, our DaVita Rewards package connects teammates to what matters most. The Clinical Quality Audit Specialist and teammates are eligible to begin receiving benefits on the first day of the month following or coinciding with one month of continuous employment. Below are some of our benefit offerings.

  • Comprehensive benefits: Medical, dental, vision, 401(k) match, paid time off, PTO cash out
  • Support for you and your family: Family resources, EAP counseling sessions, access Headspace , backup child and elder care, maternity/paternity leave and more
  • Professional development programs: DaVita offers a variety of programs to help strong performers grow within their career and also offers on-demand virtual leadership and development courses through DaVita's online training platform StarLearning.

At DaVita, we strive to be a community first and a company second. We want all teammates to experience DaVita as "a place where I belong." Our goal is to embed Diversity & Belonging into everything we do in our Village, so that it becomes part of who we are. We are proud to be an equal opportunity workplace and an affirmative action employer. As such, individuals are recruited, hired, assigned and promoted without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, protected veteran status, or any other protected characteristic.

Salary/ Wage Range

$68,400.00 to $100,400.00

Compensation for the role will depend on a number of factors, including a candidate's qualifications, skills, competencies and experience and may fall outside of the range shown. DaVita offers a competitive total rewards package, which includes a 401k match, healthcare coverage and a broad range of other benefits. Learn more at https://careers.davita.com/benefits

13d ago

Quality Improvement Auditor (Clinical and BH) -- Remote Available

Centene
Remote or Atlanta, GA
Quality Improvement Auditor (Clinical and BH) -- Remote Available - REA1218224 Description You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: Lead medical record audits, monitor and analyze clinical documentation, and modify business processes to measure member outcomes. Assess provider performance and quality of care through clinical case reviews.

Lead clinical audits for provider medical records both remotely via electronic medical records and on site to assess performance, determine trends and compile written reports summarizing findings, including clinical recommendations to assure the delivery of quality services

Lead case reviews to assess the clinical performance provided in the provider network, including written clinical summaries and recommendations

Perform ongoing quantitative and statistical analysis of the business unit's performance data to include various contracted performance measures, service utilization and member/provider complaint and quality of care trends

Coordinate with internal teams to assure audit requests are fully understood, accurately compiled and delivered timely
Perform other performance and process improvement activities

Our Comprehensive Benefits Package:

Flexible work solutions including remote options, hybrid work schedules and dress flexibility
Competitive pay
Paid Time Off including paid holidays
Health insurance coverage for you and dependents
401(k) and stock purchase plans
Tuition reimbursement and best-in-class training and development

Qualifications
Education/Experience: Bachelor's degree in Nursing, related field or equivalent experience. 3+ years of nursing or quality improvement experience.

Licenses/Certifications: Current state's RN license.
Office based position with some travel
Ideal candidate will have a background in clinical and behavioral health
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
Job: Quality Assurance Primary Location: USA-Georgia-Atlanta Organization: Peach State Health Plan Schedule: Full-time
New
15h ago

Quality Improvement Auditor (Clinical and BH) -- Remote Available

Centene Corporation
Remote or Atlanta, GA
You could be the one who changes everything for our 25 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, multi-national organization, you'll have access to competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: Lead medical record audits, monitor and analyze clinical documentation, and modify business processes to measure member outcomes. Assess provider performance and quality of care through clinical case reviews.

* Lead clinical audits for provider medical records both remotely via electronic medical records and on site to assess performance, determine trends and compile written reports summarizing findings, including clinical recommendations to assure the delivery of quality services

* Lead case reviews to assess the clinical performance provided in the provider network, including written clinical summaries and recommendations

* Perform ongoing quantitative and statistical analysis of the business unit's performance data to include various contracted performance measures, service utilization and member/provider complaint and quality of care trends

* Coordinate with internal teams to assure audit requests are fully understood, accurately compiled and delivered timely
* Perform other performance and process improvement activities

Our Comprehensive Benefits Package:

* Flexible work solutions including remote options, hybrid work schedules and dress flexibility
* Competitive pay
* Paid Time Off including paid holidays
* Health insurance coverage for you and dependents
* 401(k) and stock purchase plans
* Tuition reimbursement and best-in-class training and development

Education/Experience: Bachelor's degree in Nursing, related field or equivalent experience. 3 years of nursing or quality improvement experience.

Licenses/Certifications: Current state's RN license.

Office based position with some travel

Ideal candidate will have a background in clinical and behavioral health

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
18d ago

Remote Quality Auditor

Wipro Ltd.
Remote or Tampa, FL
Insurance Quality Assurance Auditor position will report to the Quality Assurance Manager and will focus on providing quality and professional support to the compliance team. The QA auditor is responsible for supporting total quality methods, processes, and procedures for call center sales.

In this role, the auditor will serve as a contributor to the coaching, support, training, and daily operation of the call centers. The auditor will ensure that the practice's quality, compliance, and workflow guidelines are met through call interactions within the monitoring system.

The QA Auditor is responsible for collaborating with management and compliance training departments to help ensure quality metrics are met through adherence to our best practices. The QA Auditor will provide effective and efficient monitoring and reporting that ensures maximum scoring of each assigned sales interaction.

* Responsible for performing the formal routine audits & tracking call center performance using an Agency Management System

* Track quality scores, trends, and commitments against established workflows and quality standards through call audits
* Conducts comprehensive call quality review to identify performance deficiencies
* Provides regular feedback to leadership regarding call trends or compliance issues that may arise
* Highlights immediate compliance issues
* Provide insight on behaviors, patterns, and quality compliance to management
* Identify and report on areas of opportunity to maximize consumer understanding during a sales call
* Become a subject matter expert in all practices
* Offers suggestions for process improvement to foster exceptional consumer experience
* May participate in corrective/preventive action planning & implementation related to audits
* May contribute to the development of training curriculum, as needed
* Participates in meetings with management to inform and discuss call center performance
* Identify and support other opportunities for quality improvement across the team that lead to excellent call center sales experiences
* Maintains overall objectivity in supporting the agency, call center, and consumer experience
* 1-3+ years of work experience in an insurance or healthcare Quality Auditing, Call Center, or Customer Service setting
* Ability to document processes
* Ability to listen actively and show empathy
* Excellent technical, interpersonal, written and oral communication skills required
* Ability to prioritize work efforts and has strong attention to detail
* Execute all assigned tasks within timelines
* Dedication to exceptional compliance standards
* High School Diploma or GED required
53d ago

Coding Quality Auditor - Remote

Tenet Healthcare
Remote or Frisco, TX
Coding Quality Auditor - Remote - 2105030528

Description :
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!
JOB SUMMARY
Conducts data quality audits of inpatient admissions and outpatient encounters to validate coding assignment is in compliance with the official coding guidelines as supported by clinical documentation in health record. Validates abstracted data elements that are integral to appropriate payment methodology.

ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
  • Consulting: Consults facility leaders and staff on best practices, methodology, and tools for accurately coding.
  • Chart Analysis IP, OP Coding Data auditing and validation: Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Adheres to Standards of Ethical Coding (AHIMA). Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Reviews claim to validate abstracted data including but limited to discharge disposition which impacts facility reimbursement and/or MS-DRG assignment. Adheres to Standards of Ethical Coding (AHIMA).

Reviews medical records to determine accurate required abstracting elements (facility/client/payer specific elements) including appropriate discharge disposition
IP, OP Coding : Reviews medical records for the determination of accurate assignment of all documented ICD-9-CM codes for diagnoses and procedures.
Abstracts accurate required data elements (facility/client specific elements) including appropriate discharge disposition.
  • Coding: Uses discretion and specialized coding training and experience to accurately assign ICD-9, CPT-4 codes to patient medical records.
  • Abstracting: Reviews medical records to determine accurate required abstracting elements (client specific elements) including appropriate discharge disposition.
  • Coding Quality: Demonstrates ability to achieve accuracy and consistency in the selection of principal and secondary diagnoses (including MCC & CC) and procedures. Demonstrates ability to achieve accuracy and consistency in abstracting elements defined by SOW.
  • CDI: Identifies and communicates documentation improvement opportunities and coding issues (lacking documentation, physician queries, etc.) to appropriate personnel for follow-up and resolution.
  • Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls.


Qualifications :
Conifer requires its candidates and contractors, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Ability to consistently code at 95% accuracy and quality while maintaining client specified production standards
  • Must successfully pass coding test
  • Knowledge of medical terminology, ICD-9-CM and CPT-4 codes
  • Must be detail oriented and have the ability to work independently
  • Computer knowledge of MS Office
  • Must display excellent interpersonal skills
  • The coder should demonstrate initiative and discipline in time management and assignment completion
  • The coder must be able to work in a virtual setting under minimal supervision
  • Intermediate knowledge of disease pathophysiology and drug utilization
  • Intermediate knowledge of MSDRG classification and reimbursement structures
  • Intermediate knowledge of APC, OCE, NCCI classification and reimbursement structures


EDUCATION / EXPERIENCE
  • Associates degree in relevant field preferred or combination of equivalent of education and experience
  • Three years coding experience including hospital and consulting background


CERTIFICATES, LICENSES, REGISTRATIONS
  • AHIMA Credentials, and or AAPC


PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Duties may require bending, twisting and lifting of materials up to 25 lbs.
  • Duties may require driving an automobile to off- site locations.
  • Duties may require travel via, plane, care, train, bus, and taxi-cab.
  • Ability to sit for extended periods of time.
  • Must be able to efficiently use computer keyboard and mouse to perform coding assignments.


WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Floats between clients as requested.
  • Capacity to work independently in a virtual office setting or at hospital setting if required to travel for assignment.


OTHER
  • Regular travel may be required

Job : Conifer Health Solutions
Primary Location : TX-Frisco
:
: Job Type: : Full-time Shift Type: : Days : :

Req ID: 2105030528
60d+ ago

Coding Quality Auditor - Remote

Tenet Healthcare Corporation
Remote or Frisco, TX
As a part of the Tenet and Catholic Health Initiatives family, Conifer Health brings 30 years of healthcare industry expertise to clients in more than 135 local regions nationwide. We help our clients strengthen their financial and clinical performance, serve their communities and succeed at the business of healthcare. Conifer Health helps organizations transition from volume to value-based care, enhance the consumer and patient healthcare experience and improve quality, cost and access to healthcare. Are you ready to be part of our solutions? Welcome to the company that gives you the resources and incentives to redefine healthcare services, with a competitive benefits package and leadership to take your career to the next step!

Conducts data quality audits of inpatient admissions and outpatient encounters to validate coding assignment is in compliance with the official coding guidelines as supported by clinical documentation in health record. Validates abstracted data elements that are integral to appropriate payment methodology.
ESSENTIAL DUTIES AND RESPONSIBILITIES

Include the following. Others may be assigned.

* Consulting: Consults facility leaders and staff on best practices, methodology, and tools for accurately coding.
* Chart Analysis IP, OP Coding Data auditing and validation: Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Adheres to Standards of Ethical Coding (AHIMA). Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Reviews claim to validate abstracted data including but limited to discharge disposition which impacts facility reimbursement and/or MS-DRG assignment. Adheres to Standards of Ethical Coding (AHIMA).
* Reviews medical records to determine accurate required abstracting elements (facility/client/payer specific elements) including appropriate discharge disposition
* IP, OP Coding: Reviews medical records for the determination of accurate assignment of all documented ICD-9-CM codes for diagnoses and procedures.
* Abstracts accurate required data elements (facility/client specific elements) including appropriate discharge disposition.
* Coding: Uses discretion and specialized coding training and experience to accurately assign ICD-9, CPT-4 codes to patient medical records.
* Abstracting: Reviews medical records to determine accurate required abstracting elements (client specific elements) including appropriate discharge disposition.
* Coding Quality: Demonstrates ability to achieve accuracy and consistency in the selection of principal and secondary diagnoses (including MCC & CC) and procedures. Demonstrates ability to achieve accuracy and consistency in abstracting elements defined by SOW.
* CDI: Identifies and communicates documentation improvement opportunities and coding issues (lacking documentation, physician queries, etc.) to appropriate personnel for follow-up and resolution.
* Professional Development: Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-9-CM and CPT coding. Attends mandatory coding seminars on annual basis (IPPS and OPPS, ICD-9-CM and CPT updates) for inpatient and outpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls

Conifer requires its candidates and contractors, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment activity. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

KNOWLEDGE, SKILLS, ABILITIES

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

* Ability to consistently code at 95% accuracy and quality while maintaining client specified production standards
* Must successfully pass coding test
* Knowledge of medical terminology, ICD-9-CM and CPT-4 codes
* Must be detail oriented and have the ability to work independently
* Computer knowledge of MS Office
* Must display excellent interpersonal skills
* The coder should demonstrate initiative and discipline in time management and assignment completion
* The coder must be able to work in a virtual setting under minimal supervision
* Intermediate knowledge of disease pathophysiology and drug utilization
* Intermediate knowledge of MSDRG classification and reimbursement structures
* Intermediate knowledge of APC, OCE, NCCI classification and reimbursement structures

EDUCATION / EXPERIENCE

* Associates degree in relevant field preferred or combination of equivalent of education and experience
* Three years coding experience including hospital and consulting background

CERTIFICATES, LICENSES, REGISTRATIONS

* AHIMA Credentials, and or AAPC

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

* Duties may require bending, twisting and lifting of materials up to 25 lbs.
* Duties may require driving an automobile to off- site locations.
* Duties may require travel via, plane, care, train, bus, and taxi-cab.
* Ability to sit for extended periods of time.
* Must be able to efficiently use computer keyboard and mouse to perform coding assignments.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

* Floats between clients as requested.
* Capacity to work independently in a virtual office setting or at hospital setting if required to travel for assignment.

OTHER

* Regular travel may be required
60d+ ago

Quality Auditor - Minneapolis or Home Based

Be The Match
Remote or Minneapolis, MN
Works with internal staff and Network partners to assess and improve compliance of operational processes and systems Primary accountabilities include auditing apheresis centers, laboratories, donor centers and other suppliers for compliance to applicable regulations and standards, Participates in the supplier qualification process. This position can be located in Minneapolis, MN with remote flexibility or Home-Based anywhere in the U.S.
ACCOUNTABILITIES: Quality Audits: * Serves as auditor or lead auditor for internal NMDP audits, external audits at network centers, and other entities contracted to perform regulated functions for NMDP. * Works with stakeholders and auditees to establish audit scope and depth. * Schedules, prepares for and coordinates assigned audits. Issues audit agenda; requests and reviews pre-audit information. * Conducts opening and closing meetings. * Leads or participates in audit; ensure findings and observations are identified and clearly documented. * Works with auditees, clients, and NMDP leadership to perform audit follow-up as needed. Escalates critical findings to NMDP leadership immediately. * Writes audit reports, sends reports to auditees, and works with auditees to address compliance issues. * Reviews, evaluates, and tracks audit responses; escalates overdue or unacceptable responses. * Works closely with Supplier Qualification and Biotherapies Collection Network staff to support qualification processes and client needs. * Other duties as assigned, in support of NMDP's mission and goals. REQUIRED QUALIFICATIONS: Knowledge of: * Intermediate applied knowledge of auditing principles and practices in an FDA regulated industry such as biologics, blood, tissues, pharmaceutical or medical device. * Good Manufacturing Practices (GMP) and Good Tissue Practices (GTP) required. Ability to: * Think analytically and critically; communicate effectively both verbally and in writing. * Meet deadlines and manage multiple tasks and projects simultaneously; proficiency with Microsoft Office applications; strong interpersonal skills; work independently and as part of a team. * Demonstrate technical writing skills. * 50-60% travel required. Education and/or Experience: * Bachelor's degree in medical technology, biology, biotechnology or other health-science related field. * Five years of experience as an auditor in an FDA-regulated industry such as biologics, blood, tissues, pharmaceutical or medical device. * PREFERRED QUALIFICATIONS: (Additional qualifications that may make a person even more effective in the role, but are not required for consideration) * Auditor certification preferred (ASQ, RAC, etc). Additional Information * Number of Openings: 1 * Pay Basis: Yearly * Schedule: Full-time * Driver Policy: No
60d ago

Clinical Quality Auditor (myNEXUS)

Anthem, Inc.
Washington, DC
SCHEDULE: Full-time

Your Talent. Our Vision. At my NEXUS, a proud member of the Anthem, Inc. family of companies, it's a powerful combination. It's the foundation upon which we're creating greater access to care for our members, greater value for our customers and greater health for our communities. Join us and together we will drive the future of health care.

my NEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes. Our proven clinical model connects individuals to intelligent care delivering independence at lower costs. To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform. We are continuously pioneering ways to optimize health resources for our clients and their customers. Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.

The Clinical Quality Auditor completes independent assessments of authorizations in accordance with my NEXUS policies and procedures, clinical guidelines, applicable regulatory standards and client requirements. This will ensure adherence to departmental and regulatory data integrity standards and requirements including contractual obligations with Health Plan Clients, State and Federal agencies and Center for Medicare & Medicaid Services (CMS). The Clinical Quality Auditor will support accreditation and general quality management initiatives, including but not limited to working closely with the Director of Quality Management and the Chief Clinical Officer to insure the company meets the standards for obtaining a URAC accreditation, and then subsequently works to insure the company continues to operate at such standards. The incumbent will assist with training new employees on the URAC standards and reinforce said standards with employees on an ongoing basis.
Duties/Responsibilities:

+ Independently use discretion and judgment to evaluate objective and subjective clinical documentation of member authorizations to assess performance of nursing skill and the skills of other allied health professionals, based on Business Unit expectations for performance

+ Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses and other allied health professionals

+ Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases

+ Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow my NEXUS policies, State regulations and Accreditation standards

+ Collate all data available to illustrate a full picture of an individual staff members performance (Work Force Management data, phone metrics, other)

+ Generate reports /findings of reviews for the Clinical Management Teams: in a clear, concise manner that is understandable and actionable

+ Provide consultation with Clinical Management leaders as requested to support staff coaching and development efforts

+ Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist my NEXUS employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and member engagement

+ Identifies tracks and records best practices, sharing the specifics with team leadership

+ Participate in training and performance improvement related projects to support staff development as well as assist with the training of new employees

+ The Clinical Quality Auditor will highlight key findings for implementation of performance improvement plans when necessary

+ Participate in URAC and NCQA accreditation activities

+ Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member documentation such as job aids and policies

+ Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings

+ Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings

+ Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served

+ Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner

+ Ability to work and interact with professionals as part of an interdisciplinary team

+ Self-motivated, flexible person who can flourish in an office setting with colleagues as well as in a self-structured independent setting

+ Ability to accept constructive feedback for continual improvement

+ Ability to add to a team atmosphere where a team approach is highlighted and valued

+ Thrives in a process based transactional work environment

+ Able to work independently; self-motivated with good organizational skills

+ Quickly adapt to new technology

+ Must stay abreast of all customer specific details, to ensure high quality customer service

+ Accept additional assignments willingly

Professional Responsibilities:

+ Excellent organizational, interpersonal, written and verbal communication skills

+ Maintains member confidentiality at all times

+ Capable to apply and conduct a logical approach to audits to arrive at fact-based recommendations based on source of truth documentation

+ Ability to remain a neutral party, negotiate, and drive to expected result

+ Follows all company policies related to time records

+ Has a passion for quality and performance improvement

+ Adheres to dress code, appearance is neat and clean

+ Completes annual education requirements in a timely fashion

+ Maintains confidentiality of employee, company and/or patient information at all times

+ Reports to work on time and from breaks as scheduled, completes work within designated time

+ Follows all company policies related to time records and time off policies

+ Attends staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested

+ Represents the organization in a positive and professional manner

+ Actively participates in performance improvement and continuous quality improvement (CQI) activities.

+ Complies with all organizational policies regarding compliance and ethical business practices

+ Communicates and demonstrates the mission, core values, ethics and goals of the Company, as well as the department

Required Skills/Abilities:

+ Excellent verbal and written communication skills

+ Excellent interpersonal and customer service skills

+ Excellent presentation skills

+ Excellent organizational skills and attention to detail

+ Excellent time management skills with a proven ability to meet deadline

+ Strong supervisory and leadership skills

+ Ability to prioritize tasks and to delegate them when appropriate

+ Ability to function well in a high-paced and at times stressful environment

+ Knowledge of healthcare payer and/or provider industry

+ Proficient with Microsoft Office Suite or related software

Education and Experience:

+ LPN, RN, PT, OT, PTA, or COTA license required

+ Experience preferred in Utilization Management

+ 2 or more years of clinical audit experience preferred

+ RN/LPN required in the state that you reside (must be active and unrestricted)

+ Ability to read and communicate effectively in English

+ Additional languages preferred

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For , is ranked as one of the 2020 World's Most Admired Companies among health insurers by Fortune magazine, and a 2020 America's Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

REQNUMBER: PS49977
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Average Salary For an Auditor/Quality

Based on recent jobs postings on Zippia, the average salary in the U.S. for an Auditor/Quality is $31,608 per year or $15 per hour. The highest paying Auditor/Quality jobs have a salary over $41,000 per year while the lowest paying Auditor/Quality jobs pay $23,000 per year

Average Auditor/Quality Salary
$31,000 yearly
$15 hourly
Updated October 23, 2021
23000
10 %
31000
Median
41000
90 %

Highest Paying Cities For Auditor/Quality

0 selections
CityascdescAvg. salaryascdescHourly rateascdesc
Shelton, CT
$38,491
$18.51
Watertown Town, MA
$37,773
$18.16
Weslaco, TX
$34,023
$16.36
Hillsboro, OR
$33,981
$16.34
Minneapolis, MN
$32,680
$15.71
Chicago, IL
$32,415
$15.58

5 Common Career Paths For an Auditor/Quality

Team Leader

Team leaders are responsible for managing a team for a specific project or work component. They primarily guide the team members and ensure that they are still working towards the set goals. Team leaders create strategies to reach goals, cascade the goals and strategies to team members, assign tasks, conduct periodic check-ups on the roadmap towards the goals, foster an engaging work environment, motivate and coach team members, monitor team performance, evaluate the strategies and come up with mitigating plans as needed. They are also responsible for reporting the team's progress to higher management.

Quality Engineer

A quality engineer's responsibilities include ensuring that the manufacturing processes are efficient and accurate, documenting findings that would raise concerns, conducting quality tests while observing parameters, and implementing changes as necessary to meet the highest quality standards. Quality engineers need to have excellent problem-solving and observation skills to detect any irregularities and possible malfunctions. They also must be able to communicate effectively with the clients for feedbacks and corrective adjustments, address complaints, and immediately resolve any inconsistencies made.

Assistant Manager

An assistant manager provides assistance and support to the direct manager in ensuring that the business runs smoothly with guaranteed satisfaction. An associate manager helps organize daily projects and manages employees to make sure that tasks are being done in a timely and accurate manner. Assistant managers are also expected to develop a good relationship with the whole workforce and clients to contribute to a successful and healthy workplace. An assistant manager is also required to present practical strategies for business growth, monitor daily operations, and communicate with clients for any possible suggestions and complaints.

Quality Manager

A quality manager is a professional who is responsible for ensuring that the level of quality of the company's product outputs is met for customers. Quality managers monitor and evaluate the internal production process so that they can produce statistical reports on the standard of quality and communicate them to upper management. To ensure health and safety standards, quality managers must create and maintain up-to-date product or process specifications. They also train employees on quality assurance standards and processes.

Supervisor

Supervisors are responsible for overseeing the daily functions of employees in a specific team, department, or even a work shift. They create work schedules, organize work processes and workflows, train new hires, provide necessary reports related to the team function and the employees, monitor and evaluate employee performance, and ensure that goals of the specific team or department are met. When needed, supervisors also provide guidance to employees in terms of their career or even personal challenges. They also help in fostering harmonious work relationships by resolving interpersonal conflicts at work. To be successful in their role, they must have leadership skills, time management skills, decision-making capabilities, analytical skills, and problem-solving skills.

Illustrated Career Paths For an Auditor/Quality