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Clinical Quality Auditor Job in Irving

Job Description

Summary:

This position performs audit functions for the Quality Management team and delegated vendors and partners to determine operational efficiency, adherence to regulatory requirements and achievement of quality standards.

• The Quality Clinical Auditor will conduct, review, analyze and summarize findings of audit plans for internal business units and delegated partners and entities on a monthly, quarterly and/or annual basis
• Focuses specifically on HEDIS audits and initiatives, supporting documentations and authorization to ensure compliance with regulation, policy and procedures for multiple lines of business
• This includes collecting, aggregating, sorting and communicating summary of data collected and utilizing excel pivot tables, charts and graphs to share findings and prepare materials for reporting purposes
• Assist with evaluating and analyzing ad hoc quality performance data to develop strategies for implementing Performance Improvement initiatives
• This includes identifying opportunities for improvement, problem prioritization and creating performance improvement plans for non-compliant audits and/or reports
• Contribute creative solutions and ownership of daily assignments for seamless communication and systematic completion of routine and special projects
• Working under the direction of the Quality Director, maneuvers multiple tasks independently with a fast-paced proactive vs. reactive approach to changing priorities
• Maintain tracking tools 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
• Assist departments with creating and revising audit tools, as necessary, to ensure audits and reports are value added to the business(s) owner
• Assists in assuring regulatory compliance requiring Clinical RN oversight and review
• Investigates all potential quality of care issues reported in coordination with the Medical Director and Peer Review Committee
• Responsible for maintaining timely reporting for all regulatory reporting, including medical record review and Quality Improvement Plans/Performance Improvement Plans
• Participates in maintaining compliance with URAC and NCQA accreditation standards
• Complete in-office provider audits and education as deemed appropriate pertaining to HEDIS and potential quality issues

Requirements:

• Associate degree in Nursing

Work Type: 

Full Time