New York Licensed Clinical Auditor

Job Summary

A company is looking for a Clinical Auditor: Appeals and Grievances.

Key Responsibilities

• Conduct quality audits of appeals and grievances, ensuring compliance with regulatory standards
• Review and investigate appeals and grievances requests for proper classification and resolution
• Track audit results and provide feedback to enhance departmental performance and compliance

Required Qualifications

• LPN or RN license
• 1+ years of experience in Appeals and Grievances
• High School Diploma or GED from an accredited institution
• Experience with managed care plan products and knowledge of relevant regulations
• Familiarity with systems such as TruCare, PEGA, and Microsoft Office applications