Health Business Solutions LLC

Job Description:

We are seeking a detail-oriented, knowledgeable, and proactive Clinical Quality Auditor to help ensure the integrity and quality of our clinical appeals. As an internal team member, you'll have the advantage of already being familiar with our processes and culture, making you an ideal candidate for this role. In this position, you will audit clinical appeals to ensure compliance with established guidelines, best practices, and internal quality metrics.

Key Responsibilities:

• Conduct audits of clinical appeals to ensure the use of correct appeal letter structure, adherence to the provided guidance/ medical records documentation, and consistency with payor policies and guidelines.
• Utilize all available tools, including Atlas, Epic, Cleopatra, MCG, and email correspondence to ensure the data in our completed appeals is accurate and compliant with established healthcare guidelines.
• Stay abreast of new guidance relevant to the structure of appeals and collaborate with relevant personnel to ensure the team is made aware of any such changes in a timely manner.
• Identify areas of improvement and non-compliance, providing detailed feedback and corrective action plans to relevant team-leads/team members as needed.
• Collaborate with Clinical Quality Manager and Director of Clinical Appeals to identify areas of opportunity and provide feedback to continuously improve and streamline our QA process.
• Maintain and update audit findings, tracking the resolution of issues and documenting corrective actions.
• Prepare audit reports, providing clear and concise documentation regarding relevant findings, trends, and recommendations for continuous improvement.
• Participate in team meetings and training sessions to stay updated on regulatory changes and quality assurance best practices.
• Support peer education and contribute to training sessions focused on audit findings, quality standards, and process improvements.

Key Qualifications:

• Active employment at Hbiz Solutions as a Clinical Appeals Specialist for at least 1 year (internal applicants only)
• Bachelor’s of Science in Nursing (or equivalent degree/certification)
• Three (3) years work experience as a Registered Nurse in a hospital or equivalent clinical setting
• Experience in clinical operations, clinical research, or healthcare-related fields
• Strong understanding of clinical trial protocols, Good Clinical Practice (GCP), and healthcare regulatory requirements (e.g., FDA, HIPAA, etc.)
• Demonstration of leadership skills in current role
• Detail-oriented with strong organizational, communication and analytical skills
• Excellent written and verbal communication skills, with the ability to present audit findings and collaborate with cross-functional teams
• Proficiency with audit tracking tools (Qodex) and Microsoft tools (Word, Excel, PowerPoint) for data review and visualization
• Ability to work independently and as part of a team in a fast-paced environment
• Strong problem-solving skills and the ability to prioritize tasks effectively
• Referral/Recommendation from a Team Lead/Operations Manager
• Currently in good standing in current position (i.e meeting highest quality and productivity goals)

Why Apply for This Internal Opportunity?

• Career Development: Transition into a specialized role and expand your knowledge and expertise in clinical quality assurance.
• Collaborative Environment: Work with highly skilled colleagues and contribute to improving existing company outcome to facilitate further company growth and operational excellence.
• Competitive Compensation: Enjoy a competitive salary and benefits package, with opportunities for career growth within the organization.
• Internal Mobility: Leverage your existing knowledge of company culture, processes, and systems to succeed in this new role.

How to Apply:

If you are a current HBiz employee and are interested in this opportunity, please submit your updated resume and a brief cover letter outlining your interest in the position to the Clinical Quality Manager and Director of Clinical Operations. Please note your referring Team Lead and/Operations Manager and ensure they are copied on your email application. Applications will be reviewed by the Clinical Quality Assurance team, and candidates will be contacted for interviews based on suitability.

We encourage all internal candidates recommended by a Team Lead to apply and look forward to seeing how you can contribute to maintaining and improving the quality of our clinical appeals!