Quality Review Specialist Jobs

The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.

Why work for MJHS?:

• Dependent Tuition Reimbursement for clinical staff!
• Sign-on Bonuses OR Student Loan Assistance for clinical staff
• Flexible spending
• Tuition Reimbursement for all full and part-time staff
• Two retirement plans! 403(b) AND Employer Paid Pension
• And MORE!
• FREE Online RN to BSN and MSN degree programs!
• Affordable medical, dental and vision coverage for employee and family members
• Generous paid time off

Responsibilities:

This position is responsible for quality assurance, accuracy and overall integrity of the care management records and documentation completed by Care Management staff. This role is to ensure compliance with NYS DOH and CMS regulations through development of auditing tools, specifically validating all data collected. Analyzes collected audit data, identify trends for staff re-training and implementing corrective action plans in collaboration with Clinical management staff. Provides support to Directors, Managers and Supervisors to insure that all documentation and reporting requirements are prepared and maintained in a professional and well-coordinated manner. This position is responsible for reviewing, collecting and preparing evidence packets for all scheduled Fair Hearings. managed care nurse, managed care rn, nursing, rn, nurse, care management

Qualifications:

• Working knowledge of audit techniques and methodologies.
• Excellent written and verbal communication skill.
• Possess strong critical thinking skills and knowledge of Medicare and Medicaid regulations.
• Computer literate, Windows, Excel, Word, Visio and data base programs required. Powerpoint preferred.
• Licensed with current Registration to practice as Registered Professional Nurse in NYS.
• Work effectively within interdisciplinary team environment.
• Ability to set priorities and to handle multiple assignments.
• Working knowledge of State and Federal regulations.
• Graduate from an accredited School of Nursing. BSN or BS degree preferred.
• Strong interpersonal and organizational skills.
• Excellent analytic skills, interpretation of data.
• Minimum of two (2) years care management experience required.