Company Statement
EmblemHealth is one of the nation’s largest not for profit health insurers, serving members across New York’s diverse communities with a full range of commercial and government-sponsored health plans for employers, individuals, and families. With a commitment to value-based care, EmblemHealth partners with top hospitals and doctors, including its own AdvantageCare Physicians, to deliver quality, affordable, convenient care. At over a dozen EmblemHealth Neighborhood Care locations, members and non-members alike have access to community-based health and wellness guidance and resources. For more information, visit emblemhealth.com.
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Clinical Quality Auditor - Hybrid
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- EmblemHealth
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- Feb 24, 2026 Post Date
Summary of Job
As part of the overall clinical audit process, assess and audit medical record charts to ensure compliance with internal (EmblemHealth) and external regulatory and accreditation requirements. Compare collected data against Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Assurance Reporting Requirements (QARR) audit standards. The information abstracted from completed chart review will directly impact EmblemHealth’s Quality award programs, including Medicare Stars and Quality Incentive Awards. Identify and report significant and/or patterns of variances from established standards that can negatively impact scores. May provide process improvement recommendations to safeguard a high quality of clinical care for patients.
Responsibilities
- Support EmblemHealth’s Quality program by conducting targeted chart review to enhance quality scores during the annual Medical Record Review project as well as throughout the year for Supplemental data collection.
- Review each chart to determine if the patient meets the selection criteria.
- Complete one audit tool (paper form or row in the electronic spreadsheet) for each patient that meets the criteria.
- Ensure that patient confidentiality is protected.
- Utilize appropriate tools, processes, standards, and techniques to perform audits.
- Identify variations from established standards in audit results.
- Ensure that these variations are reported accurately and timely.
- May provide assistance in the compilation/interpretation of data and results.
- Conduct telephonic outreach calls to EmblemHealth Members in support of various HEDIS/QARR measures, to complete health assessments, and collect historical information that directly impacts Quality results.
- Ensure that relevant areas of patient care are covered so that a complete picture can be reported on (i.e., accessibility of care, communication with providers, care coordination, interactions with staff).
- Provide recommendations on process improvements based on audit results.
- Perform other duties/tasks as required or directed.
Qualifications
- Bachelors’ Degree.
Current licensed NP, LPN or RN with 3 - 5years of clinical experience in critical care or med-surgical experienced (Required)
- 3 – 5 years of relevant, professional work experience (Required)
- 2 – 3 years’ experience in a managed care environment (Preferred)
- Knowledge of HEDIS/QARR/Star specifications (Required)
- Proven track record of accurately performing audits within specified parameters of quality and timeliness (Required)
- Advanced clinical assessment skills and the ability to apply clinical criteria and guidelines (Required)
- Attention to detail, and the ability to proficiently read and interpret medical records (Required)
- Experience with EPIC (Preferred)
- Knowledge of ICD-10 codes (Required)
- Excellent communication skills - verbal, written, interpersonal (Required)
- Must have ability to physically travel between sites (Required)
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We value the diverse backgrounds, perspectives, and experiences of our workforce. As an equal opportunity employer, we consider all qualified applicants for employment regardless of race, color, religion, sex, sexual orientation, age, creed, citizenship, gender identity, pregnancy, marital status, national origin, disability, veteran status, or any other protected characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, Emblemhealth may provide work visa sponsorship for certain positions.