Clinical Quality Auditor II - RN / SW

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

Horizon Casualty Services - Responsible for the quality review of claims to enhance the clinical, network, and case management services offered by Horizon Casualty Services, Inc. (HCS). Also responsible for coordinating all aspects of continuing clinical, nursing, and Certified Case Manager (CCM) in-service programs and medical consultant services. Health Affairs - Quality Management - Responsible for conducting file audits for all areas of clinical operations. These audits review daily business practice compliance to regulatory compliance relative to NCQA, URAC and CMS.

Horizon Casualty Services -

• Performs audits on claims and correspondence to determine the accuracy and

completeness of the physician network and medical consultants.

results include accuracy rates, turnaround times, denial rates, error trends,

and operational effectiveness.

audit point sheets and trending for the Physician Excellence and Medical

Consultant Program.

established department guidelines.

initiatives.

issues and trends.

consulting staff.

Health Affairs - Quality Management -

Core Individual Contributor Competencies :

Personal and professional attributes that are critical to successful performance for Individual Contributors :

Education / Experience :

Additional licensing, certifications, registrations :

Knowledge :

Skills and Abilities :

Travel (If Applicable)

Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware

Salary Range : $79,100 - $105,945

​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to : education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes :

Comprehensive health benefits (Medical / Dental / Vision)

Retirement Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Disclaimer :

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.