Clinical Quality Auditor Role Description
As the Clinical Quality Auditor, you will be responsible for completing quality review processes for care management programs. This role is responsible for ensuring appropriate clinical and care delivery practices are utilized and case documentation meets established standards consistently to support meeting internal and external quality standards, compliance, and expectations.
As an auditor, you will utilize clinical experience, expertise, and quality guidelines to review patient files, care plans and interactions and care plans against appropriate applicable quality criteria in conjunction with program, accreditation and industry requirements. You will support various Kidney Hero roles (clinical and non-clinical) regarding case auditing, outcomes and coaching, quality improvement strategies, resource development and other activities to promote continuous quality improvement.
This quality improvement support will be provided to operational managers and leadership to communicate and facilitate resolution for quality risks, such as root cause analysis and remediation recommendations. As a quality auditor, you will serve as a quality liaison and advisor to various strive roles and departments such as kidney heroes, operational leadership and managers, education and training colleagues.
You will serve as a care manager and quality subject matter expert, applying critical thinking and decision-making skills to determine medical appropriateness while maintaining production goals and Quality Assurance standards. This role reports to the Sr. Manager, Clinical Quality Auditor.
Day-to-Day Responsibilities
Reviews and evaluates various patient file documentation and encounters, such as patient assessments/surveys, care plans, and recorded patient encounters against criteria to determine appropriate caredelivery and documentation based on clinical practice guidelines and industry standards.
Meets and maintains daily, weekly, monthly auditing productivity goals and quality assurance standards.
Reviews internal assessments and care plans against NCQA case management and population health standards for timeliness and accuracy of documentation.
Prepares, communicates, and collaborates with kidney heroes regarding individual staff audit findings, documentation of deficiencies, coaching, and education regarding audit activities and findings as well as reports for clinical management and supervisors of the audited resources.
Assists with development, review, revision, and maintenance of quality audit tools, processes, and resources as requested.
Identifies and assists with risk and gap resolution regarding clinical auditing processes, resources, clinical software assessments, and care plans for compliance with accreditation and regulatory standards.
Identifies and communicates system and/or operational issues hindering attainment of quality performance standards.
Abstracts review related data/information accurately on review tool by the appropriate means. Accurately submits all administrative and review related documents to appropriate parties.
Identifies and escalates situations which may pose quality, compliance, and safety risks that may adversely affect business operations.
Supports program and clinical compliance requirements and activities.
Participates in accreditation activities as needed such as case preparation or presentation, reviewing cases with internal and external clients.
Participates and supports internal or external action plans to enhance the organizations quality and compliance posture.
Minimum Qualifications
Active, unrestricted RN license.
6+ years combined of related education, experience, or certification.
Internet Connectivity - Min Speeds: 3.8Mbps/3.0Mbps (up/down): Latency <60ms.
Ability to travel and be onsite to meet business needs.
Preferred Qualifications
Bachelors degree in nursing or another healthcare-related field preferred.
Application of NCQA program(s) accreditation standards and processes experience.
NCQA Accreditation Survey experience or other industry related audits.
Proficiency in Microsoft Office, Adobe Acrobat, and internet/web navigation.
Case Management Certification.
Knowledge of the organization of medical records, medical terminology, and disease process.
About You
Strong clinical assessment and critical thinking skills.
Attention to excellence - quality driven, detailed oriented, innovative, and accountable.
Excellent verbal and written communication skills.
Ability to work in a team environment.
Flexibility and strong organizational skills needed.
Annual Base Salary Range
$74,000 - $90,000