Clinical Quality Assurance Auditor

Job Responsibilities

• Presenting and communicating audit results to appropriate parties; participates in the development of procedures and standards that support and enhance all lines of business’ quality of care goals.
• Schedule and perform routine facility, practitioner site, and medical record reviews, utilizing established clinical audit tools reflective of national accreditation standards and regulatory agency requirements.
• Identifying and evaluating areas of exposure, potential problems and liabilities. Analyze clinical data to improve individual provider compliance with education; provide oversight for regional contract staff and coordinate the effort of retrieval of HEDIS and/or STARS records; complete medical record audits for HEDIS and/or STARS data collection or quality of care reviews as required.
• Providing required documents and consulting support for quality and compliance audits.
• Various immunizations and/or associated medical tests may be required for this position.

Job Qualifications

Education

• Bachelor’s Degree in Health Care related field or equivalent work experience.

Experience

• 4 years – Health Care experience required.
• 1 year – Managed care experience or experience with Quality Medical Record Review.

Skills\Certifications

• Demonstrated presentation and team facilitation skills
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Excellent oral and written communication skills
• Excellent time and project management skills
• Strong analytical, planning, organizational and research skills

License

• Registered Nurse (RN) with active license in the state of Tennessee or hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

We are seeking a skilled and organized RN to join our Clinical Quality Assurance team. This role involves conducting medical record reviews and provider audits to support HEDIS, STARS, quality of care initiatives, accreditation, and compliance requirements. Key responsibilities include analyzing clinical data from electronic medical records, collaborating with providers to enhance quality of care and best practices, improving compliance with HEDIS and accreditation standards, and ensuring our members receive safe and high-quality care.

This is a remote position with some travel required for in-office reviews and audits in the greater Nashville area.  If you have experience with audits, medical record reviews, HEDIS, accreditation, and provider education, we encourage you to apply!