Nurse Auditor

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for under-served communities.

Best People, Best Solutions, Best Results

Job Summary:

This position will support the Medicare Advantage and Prescription Drug Plan Audits conducted by the Centers for Medicare and Medicaid Services (CMS). The positions primary responsibility will be to support the Organizational Determinations, Appeals, and Grievances (ODAG) and Special Needs Plan, Model of Care (SNP-MOC) of the Medicare Program Audits.

Essential Duties and Responsibilities include some or all of the following. Other duties may be assigned.

• Completes audits to meet applicable contract requirements
• Support Audit Engagement Notice and Universe Selection, Audit Field Work, and Audit Reporting Phases of the process.
• Effectively identifies and resolves issues and determines root cause.
• Interacts with health plans to obtain additional case specific information, as needed.
• Has basic understanding of the use of the computer for entry and research.
• Responsible for case specific or plan specific data entry and reporting.
• Participates in internal and external focus groups and other projects, as required.
• Identifies opportunities to improve processes and procedures.
• Has the responsibility and authority to perform their job and provide customer satisfaction.
• May participate as an audit/investigation team member for both desk and field audits
• Has developed expertise with standard concepts, practice and procedures in field. Relies on limited experience and judgment to plan and accomplish goals.
• Performs a variety of tasks some requiring independent thought and research. A degree of creativity and latitude is required.

To perform the job successfully, an individual should demonstrate the following competencies:

• Analytical - Synthesizes complex or diverse information; Collects and researches data; Uses intuition and experience to complement data.
• Problem Solving - Gathers and analyses information skillfully; Identifies and resolves problems.
• Judgment - Supports and explains reasoning for decisions.
• Written Communication - Writes clearly and informatively; Able to read and interpret written information.
• Quality Management - Looks for ways to improve and promote quality; Demonstrates accuracy and thoroughness.
• Interpersonal Skills - Focuses on solving conflict, not blaming; Maintains confidentiality; Listens to others without interrupting; Keeps emotions under control; Remains open to others' ideas and tries new things.
• Teamwork - Balances team and individual responsibilities; Exhibits objectivity and openness to others' views; Gives and welcomes feedback; Contributes to building a positive team spirit; Puts success of team above own interests; able to build morale and group commitments to goals and objectives; Supports everyone's efforts to succeed.
• Professionalism - Approaches others in a tactful manner; Reacts well under pressure; Treats others with respect and consideration regardless of their status or position; Accepts responsibility for own actions; Follows through on commitments.

Education and/or Experience

• BSN OR an RN with additional current and active degree/license/certification/s in a relevant healthcare discipline (i.e., CPC, CPHM, CFE, CCM, HCAFA).
• Must possess at least five years experience.
• At least one year healthcare experience that demonstrates expertise in conducting utilization reviews or audits
• ICD-9 coding, CPT coding, and knowledge of Medicare Part C regulations strongly preferred.

Certificates, Licenses, Registrations

• Current, active and non-restricted RN licensure required.

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.