Clinical Quality Auditor (myNEXUS)

Description SHIFT: Day Job SCHEDULE: Full-time Your Talent.

Our Vision.

At myNEXUS, a proud member of the Anthem, Inc.

family of companies, it’s a powerful combination.

It’s the foundation upon which we’re creating greater access to care for our members, greater value for our customers and greater health for our communities.

Join us and together we will drive the future of health care.

myNEXUS is a technology-driven, care and benefit management service that enables individuals to live healthier lives in their homes.

Our proven clinical model connects individuals to intelligent care delivering independence at lower costs.

To maximize health delivery, we consistently leverage our: Innovative Technologies, Advanced Clinical Expertise, and Proprietary Network Engagement Platform.

We are continuously pioneering ways to optimize health resources for our clients and their customers.

Through our proprietary network management and engagement programs, we realize enhancements in quality, outcomes, and care effectiveness.

Job Summary: The Clinical Quality Auditor completes independent assessments of authorizations in accordance with myNEXUS policies and procedures, clinical guidelines, applicable regulatory standards and client requirements.

This will ensure adherence to departmental and regulatory data integrity standards and requirements including contractual obligations with Health Plan Clients, State and Federal agencies and Center for Medicare & Medicaid Services (CMS).

The Clinical Quality Auditor will support accreditation and general quality management initiatives, including but not limited to working closely with the Director of Quality Management and the Chief Clinical Officer to insure the company meets the standards for obtaining a URAC accreditation, and then subsequently works to insure the company continues to operate at such standards.

The incumbent will assist with training new employees on the URAC standards and reinforce said standards with employees on an ongoing basis.

Duties/Responsibilities: Independently use discretion and judgment to evaluate objective and subjective clinical documentation of member authorizations to assess performance of nursing skill and the skills of other allied health professionals, based on Business Unit expectations for performance Applies advanced knowledge to conduct multispecialty subjective assessments to evaluate the skills of nurses and other allied health professionals Consults with Medical Directors to calibrate on subjective assessments to ensure consistency of feedback related to complex, high risk cases Responsible to ensure evaluation tool components for subjective skills assessments comply with quality standards and follow myNEXUS policies, State regulations and Accreditation standards Collate all data available to illustrate a full picture of an individual staff members performance (Work Force Management data, phone metrics, other) Generate reports /findings of reviews for the Clinical Management Teams: in a clear, concise manner that is understandable and actionable Provide consultation with Clinical Management leaders as requested to support staff coaching and development efforts Assist the Clinical Management team, as needed, to determine areas that require immediate remediation and assist myNEXUS employees to stay ahead of changing information while improving the quality and effectiveness of clinicians and member engagement Identifies tracks and records best practices, sharing the specifics with team leadership Participate in training and performance improvement related projects to support staff development as well as assist with the training of new employees The Clinical Quality Auditor will highlight key findings for implementation of performance improvement plans when necessary Participate in URAC and NCQA accreditation activities Work with colleagues across business units to ensure that process and procedural changes are reflected in staff member documentation such as job aids and policies Assist with gathering data for routine reporting with other team members to be used for day-to-day purposes and at meetings Maintain a tracking tool that will log unacceptable areas in the workflow and staff documentation performance indicating improvement is needed for discussion with management and/or at departmental team meetings Responds to and evaluates self-performance and adjusts performance related to feedback from manager and teams served Ability to communicate in person, by phone, or via e-mail in a professional and friendly manner Ability to work and interact with professionals as part of an interdisciplinary team Self-motivated, flexible person who can flourish in an office setting with colleagues as well as in a self-structured independent setting Ability to accept constructive feedback for continual improvement Ability to add to a team atmosphere where a team approach is highlighted and valued Thrives in a process based transactional work environment Able to work independently; self-motivated with good organizational skills Quickly adapt to new technology Must stay abreast of all customer specific details, to ensure high quality customer service Accept additional assignments willingly Professional Responsibilities: Excellent organizational, interpersonal, written and verbal communication skills Maintains member confidentiality at all times Capable to apply and conduct a logical approach to audits to arrive at fact-based recommendations based on source of truth documentation Ability to remain a neutral party, negotiate, and drive to expected result Follows all company policies related to time records Has a passion for quality and performance improvement Adheres to dress code, appearance is neat and clean Completes annual education requirements in a timely fashion Maintains confidentiality of employee, company and/or patient information at all times Reports to work on time and from breaks as scheduled, completes work within designated time Follows all company policies related to time records and time off policies Attends staff meetings as scheduled and reads all staff meeting minutes and other written documents as requested Represents the organization in a positive and professional manner Actively participates in performance improvement and continuous quality improvement (CQI) activities.

Complies with all organizational policies regarding compliance and ethical business practices Communicates and demonstrates the mission, core values, ethics and goals of the Company, as well as the department Required Skills/Abilities: Excellent verbal and written communication skills Excellent interpersonal and customer service skills Excellent presentation skills Excellent organizational skills and attention to detail Excellent time management skills with a proven ability to meet deadline Strong supervisory and leadership skills Ability to prioritize tasks and to delegate them when appropriate Ability to function well in a high-paced and at times stressful environment Knowledge of healthcare payer and/or provider industry Proficient with Microsoft Office Suite or related software Education and Experience: LPN, RN, PT, OT, PTA, or COTA license required Experience preferred in Utilization Management 2 or more years of clinical audit experience preferred RN/LPN required in the state that you reside (must be active and unrestricted) Ability to read and communicate effectively in English Additional languages preferred Anthem, Inc.

has been named as a Fortune 100 Best Companies to Work For , is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes.

To learn more about our company and apply, please visit us at

An Equal Opportunity Employer/Disability/Veteran.

Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.


Related Post