Clinical Auditor – Appeals and Grievances
Posted 2026-05-06
Remote, USA
Full-time
Immediate Start
- Job Description:
- performs audit functions for Healthfirst clinical teams and vendors
- maintains tracking tools to log audit results
- assists with evaluating and analyzing aggregate quality performance data
- develops strategies for business performance improvement initiatives
- assists with creating and revising audit tools
- applies clinical and critical thinking skills to evaluate quality and effectiveness of case management
- Requirements:
- NYS LPN or RN license
- unexpired NYS driver's license or NYS ID (if residing outside of NYS, must obtain a NYS ID before employment)
- relevant previous work experience (e.g. medical records review; claims processing; utilization/case management)
- knowledge of Department of Health (DOH) and Local Department of Social Services and CMS regulations
- nursing experience in acute, sub-acute or long-term care (LTC) setting or managed long-term care plan (MLTCP, FIDA)
- experience with systems: CareEnhance Clinical Management Software (CCMS), TrueCare, PEGA, Citrix, RightFax, VoIP, EMR, MACESS
- language preferences - Spanish, Russian, French, Creole, Mandarin, Cantonese
- intermediate Microsoft Word, Excel, and Outlook skills
- time management, critical/creative thinking, project management, communication, and problem-solving skills
- Benefits:
- medical
- dental
- vision coverage
- incentive and recognition programs
- life insurance
- 401k contributions