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 guidanc...