Horizon Blue Cross Blue Shield of New Jersey · 12 hours ago
Clinical Quality Auditor II - RN/SW
Hopewell, NJ
Full-time
Onsite
Mid Level
$79K/yr - $106K/yr
3+ years expHorizon Blue Cross Blue Shield of New Jersey is a leader in health solutions, dedicated to improving health care quality and member experience. The Clinical Quality Auditor II is responsible for conducting audits on claims and ensuring compliance with regulatory standards, while also coordinating clinical in-service programs and evaluating quality audit procedures.
Health Care
Responsibilities
Performs audits on claims and correspondence to determine the accuracy and completeness of the physician network and medical consultants
Responsible for scheduling and coordinating all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs
Creates and maintains medical consultant calendar to ensure daily coverage
Maintains records and prepares reports on quality audit results. Quality results include accuracy rates, turnaround times, denial rates, error trends, and operational effectiveness
Evaluates quality audit procedures, including quality scorecards, matrixes, audit point sheets and trending for the Physician Excellence and Medical Consultant Program
Responds to internal/external clinical customer complaints/appeals within established department guidelines
Conducts offsite meetings to educate physicians on process improvement initiatives
Participates in audits based on operations requests and based on mandate issues and trends
Responsible for verification of all professional licenses for RN & medical consulting staff
Participates in departmental process improvement initiatives
Completes other assigned functions as requested by management
Conduct quarterly file audits for all lines of business against business Process Flows to determine compliance with regulatory standards according to NCQA, URAC and CMS
Analyze, prepare, and distribute quarterly audit outcomes including error trends, to the Business Unit Directors
Conduct monthly CMS-CAPs audits against business Process Flows in order to evaluate compliance with Medicare standards
Primary responsibility for documentation of CMS-CAPs results in SharePoint database and generation of communication/notification to Directors regarding the outcome including the analysis of error trends. Outcomes are then used for process improvement recommendations and changes as well as education/training
Serves as database administrator and facilitates biannual MCG-IRR testing (Milliman Care Guidelines-Inter Rator Reliability) that is administered to clinical and medical director staff. This includes general maintenance and troubleshooting during entire testing period. Notification of testing dates to staff, analysis of final reports and submission of reports to functional unit Directors and Medical Management Committee for follow up education of staff by Management
Conduct ad hoc file audits against business process flows when new business practices are set in place to monitor adherence to Process Flow as it relates to regulatory compliance
Completes other assigned functions, including special projects, as requested by management
Qualification
Required
Minimum of three (3) years clinical experience
Strongly prefers a minimum of three (3) years clinical quality or audit experience
Active Unrestricted NJ RN, LCSW, LMFT, LSW or LPC License Required
Requires current Registered Health Information Technologies (RHIT) or Certified Professional Coder designation from the American Academy of Professional Coders or a Certified Coding Specialist, P from the American Health Information Management (AHIMA)
Proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Microsoft Outlook
Knowledge of applications including but not limited to: Care Planner Web, UCSW, Appeal Pro, Care Radius, SharePoint, Membership, Benefits, Business Objects and CMS web sites
Excellent verbal and written communication skills
Analytical & Problem Solving
Continuous Improvement
Information & Knowledge Sharing
Process Management
Interpersonal & Client Relationship
Presentation
Preferred
Bachelor's degree
Knowledge of audit methodologies and procedures
Benefits
Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement
Company
Horizon Blue Cross Blue Shield of New Jersey
Horizon Blue Cross Blue Shield of New Jersey is a company that provides health insurance products.
5001-10000 employees
H1B Sponsorship
Horizon Blue Cross Blue Shield of New Jersey has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (7)
2024 (7)
2023 (6)
2021 (1)
Funding
Current Stage
Late StageLeadership Team
Gary St. Hilaire
President & Chief Executive Officer
Recent News
2026-01-06
2025-12-29
2025-12-25
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