QA Auditor (Remote) - RN

Company: Med-Metrix LLC
Location: Garden City
Posted on: June 26, 2025

Job Description:

Job Purpose The QA Auditor performs audit functions across Client Teams to determine operational efficiency, adherence to internal processes and procedures as well as regulatory requirements, and achievement of quality standards. This role requires an in-depth understanding of the denials management process, a clinical background, attention to detail, and the ability to effectively assess the quality of work completed. The QA Auditor will work closely with internal teams to provide feedback, maintain high standards of quality, and ensure compliance with established processes. Duties and Responsibilities Audit Denials Management Processes: Conduct regular audits of work performed by appeal writers and automated processes to ensure adherence to internal policies and quality standards in the denials management process. Review and Analyze Denials: Evaluate how denials are handled, ensuring that all necessary steps are followed, documentation is accurate, and appropriate actions are taken. Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals. Provide Feedback and Recommendations: Offer constructive feedback to appeal writers based on audit results, identifying areas for improvement and providing guidance on corrective actions. Provide feedback on automated processes to ensure the highest levels of efficiency in overturning denials. Documentation and Reporting: Maintain accurate records of audit findings and track trends or recurring issues in the denials management process. Prepare reports to share with management and relevant teams. Develops strategies for business performance improvement initiatives. This includes: identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports System Navigation: Utilize and navigate multiple internal systems (e.g., claims processing systems, communication tools) to review audit data and provide feedback. Adapt to new systems as necessary. Collaborate Across Teams: Work closely with appeal writers, managers, and other stakeholders to foster a collaborative approach to quality improvement and process optimization. Additional duties as assigned Qualifications State Licensed RN In-Depth Knowledge of Denials Management: Strong understanding of the denials management process, including common causes of denials and strategies for resolution. Relevant Prior Work Experience: May include medical records review, claims processing, utilization/case management in a clinical practice or managed care organization, Clinical Appeal Writer, etc. Proficiency in Microsoft Office: Advanced knowledge of Microsoft Word, Excel, and Teams for communication, data analysis, and reporting. Adaptability and Learning Ability: Ability to quickly learn and effectively navigate multiple software systems, providing accurate and timely feedback. Attention to Detail: Strong analytical skills with the ability to detect issues, inconsistencies, and areas for improvement in the denials management process. Communication Skills: Excellent written and verbal communication skills, with the ability to present findings clearly and professionally along with the ability to build and maintain positive relationships with cross-functional teams and interact with all levels of management. Organizational Skills: Ability to manage multiple audits simultaneously while maintaining accuracy and efficiency. Preferred Qualifications Experience working in a healthcare or insurance environment, particularly with claims and denials management. Familiarity with common claims management and denial resolution systems. Experience in quality auditing or process improvement initiatives. Familiarity with MCG and Interqual guidelines and processes. Working Conditions Ability to travel to other office locations and company events as needed Ability to arrive early or stay late as needed Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear. Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress. Work Environment: The noise level in the work environment is usually minimal. Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

Keywords: Med-Metrix LLC, East Hartford , QA Auditor (Remote) - RN, Administration, Clerical , Garden City, Connecticut