• Clinical QA Auditor

    Job Locations US-VA-Glen Allen
    Job ID
    2018-5338
  • About Us

    Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier.
    By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia.
     
    At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life.
     
    If this sounds like you, read on!

    Overview

    The Clinical QA Auditor will effectively perform reviews of case management data submitted to DMAS by VA Premier’s Regulatory Reporting to ensure the accuracy of the data reported and conducting member chart audits to ensure that VA Premier’s electronic medical records are complete and in compliance with internal policies and procedures, Federal, State, local and regulatory laws/agencies. The Clinical QA Auditor will work closely with Regulatory Reporting and with the Medical Management’s Case Management/Care Coordination teams to assist in establishing an oversight framework for the Health Plan.

    Our Medical Management department educates members and empowers them to become active participants in their coordinated health care plans. This team of knowledgeable professionals in their field provide services to include Utilization Review, Medical Outreach, Case Management, Disease Management, Credentialing, Social Work as well as Grievance and Appeals.

    Responsibilities

    • Execute testing on routine and non-routine member chart audits; perform and document chart audit procedures in work papers including follow up with Case Management/Care Coordination regarding issues identified.
    • Completely and accurately document reviews of regulatory reporting data and chart audits, by stating the audit testing/review performed, findings/exceptions and recommendations.
    • Assist in preparing written reports to inform management of findings and appropriate action plans to address issues identified.
    • Track all issues identified during the audits/reviews and ensure appropriate follow up activities are being performed to validate implementation of management action plans.
    • Assist in internal audit/review engagements, including: scheduling; planning; coordinating kick-off meetings, weekly status update, and exit/closing meetings.
    • Develop an understanding of the operations, processes, and procedures in accordance to State and Federal contracts.
    • Review policies and procedures, laws and regulations through the inspection of operations, processes, retrieval and review of documents and investigation of irregularities and errors.
    • Perform analysis of data to determine risks, trends, and outliers.
    • Other duties/projects as assigned.

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • Active and un-encumbered licensure as a Registered Nurse in the state of Virginia or multi-state privilege
    • Bachelor’s degree preferred

    SPECIAL KNOWLEDGE AND/OR SKILLS

    • Knowledge of Microsoft software (Word, PowerPoint, and Excel)
    • Excellent organizational and interpersonal skills.
    • Ability to follow instructions accurately and efficiently; proactive in asking clarifying questions.
    • Ability to work effectively with co-workers as a team member.
    • Ability to communicate effectively and professionally, both orally and in writing.
    • Working knowledge of the chart review/audit process.
    • Working knowledge of Medicare/Medicaid guidelines.

    WORK BACKGROUND EXPERIENCE

    • At least 2 years’ experience working in a clinical setting (such as hospital, long term care, home health, case management, quality)
    • Minimum 1 year auditing/quality assurance (QA) review experience, preferably in Healthcare industry

    PHYSICAL REQUIREMENTS

    • Physical health sufficient to meet the ergonomic standards and demands of the position.

     

    All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE

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