Quality Audit Specialist

ESSENTIAL FUNCTIONS

1. Apply structured auditing criteria to abstract medical records, and accurately enter the results of chart audits into the healthplans database.

2. Abstract medical record documentation submitted for HEDIS measures, used annually for reporting to National Committee for Quality Assurance (NCQA). The HEDIS measures are used to assist in measuring quality of health care provided to healthplan members.

3. Maintains productivity level with less than a 5% error rate in record abstraction and data entry on an ongoing basis.

4. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

5. Maintain complete confidentiality of company related business.

6. Maintain effective communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS

Registered Nurse (RN) with unrestricted license in state or Licensed Practical Nurse.

3+ years relevant experience.

Experience in utilization review, quality assurance, and/or medical record and site review audits.

Knowledge of medical terminology standard medical practices, formal quality improvement process, and federal, state, accreditation regulations and standards.

Verbal and written communications skills .

PC proficiency to include Word and Excel.

Active LPN or RN License. HEDIS Abstraction experience

PREFERRED JOB REQUIREMENTS

HEDIS abstracting clinical information experience.

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