Quality Auditor - RN Job ID: PKR032018-11137 Description: Job Summary: This position is responsible for quality review of claims, correspondence, membership, and telephone inquiries to assure accuracy and efficiency across multi-disciplinary lines. This position is also responsible for conducting follow up reviews to ensure that deficiencies have been corrected. Responsibilities: Performs audits on claim, correspondence, membership, and telephone to determine the accuracy levels and assess the efficiency of the operations areas. Maintains records and prepare reports on quality audit results. Quality results include accuracy rates, error trends, and operational effectiveness. Coordinates and prepares formal written quarterly quality error rate reports to assure accurate internal reporting. Reviews and analyzes systemic and processing methods to identify problems and recommend modifications for the overall improvement of accuracy efficiency. Communicates to operations and the Methods and Procedure unit any inconsistencies with existing policies and procedures. Assists with overall evaluation of the quality audit procedures, including quality scorecards, matrixes, audit point sheets (MTM), trending, etc. Participates in process improvement initiatives. Performs focused audits as requested by operations or as a result of mandate issues or trends. Identifies and documents deficiencies and trends both within the unit and outside the unit. Conducts follow up reviews to ensure that deficiencies have been corrected. Education/Experience: Prefers a Bachelor's Degree from an accredited college or university. Requires a minimum of 1 - 2 years clinical nursing experience. Requires a minimum of one (1) to two (2) years experience in a quality or audit function. Requires a minimum of two (2) years customer service experience, including claim, correspondence, telephone, and enrollment processing. Knowledge: Requires complete knowledge of claims processing system including data entry, pend resolution, adjustments and inquiry skills. Requires knowledge of one or more lines of business of group health. Requires knowledge of personal computers and applicable software packages. Requires knowledge of audit procedures and methodologies. Skills and Abilities: Requires strong verbal and written communication skills. Requires strong interpersonal communication skills. Requires strong mathematical skills. Requires strong analytical skills. Requires strong PC skills. Special Licenses and Certifications: Active Unrestricted NJ RN License Required. The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent. 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. Requirements: Education Bachelors Job Level Individual Contributor Expertise --Horizon NJ Health Job Type Full Time Location Hopewell, NJ