Job Description

Your Role

The Quality Review team completes audits of front-line staff to ensure alignment with department processes and regulatory compliance. Quality Assurance Auditors also provide coaching and work closely with business leaders to drive optimal results. The Quality Assurance Auditor, Specialist will report to the Quality Review Senior Manager. In this role you will develop performance metrics audit tools, evaluate performance, and provide coaching to ensure that staff have the skills and knowledge required to be successful in Appeals & Grievance (AGD).

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work
In this role, you will:

• Be responsible for performing audits that are routine in nature where limited judgment is required
• Focus on single area of expertise or line of business (Claims, Inquiry, Enrollment); objectively review and interpret standards, procedural documentation and contract and legal verbiage
• Identify and document audit observations and findings
• Notify Supervisor when communications with operations are necessary; coordinate appropriate messaging
• Identify and resolve routine problems independently; escalate issues with Supervisor as appropriate
• Contributes to meeting and improving compliance performance
• Review audit data to identify care gaps, compliance risks, and trends
• Provide developmental coaching and support to all staff to improve the skills and competencies required to successfully perform work
  

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 7 years of prior relevant experience
• Attention to details and the ability to communicate effectively
• Auditing experience preferred
• Experience in AGD preferred
• Knowledge of Health Plan operations, lines of business, general healthcare industry standards
• Strong organizational skills to conduct audits and reporting timely
• Hands-on experience using MS Office applications including Excel, Word, Outlook, PowerPoint preferred

Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.