Grievance & Appeals Quality Assurance Auditor

Partnership HealthPlan of California; California (MO); On-site; USD 58,000 - 73,000; Full time

Job summary

Partnership HealthPlan of California is seeking an Internal Auditor within the Grievance & Appeals Department to assess the quality of grievance, appeal, and State Hearing investigations, ensuring DHCS and NCQA requirements are met.

You will conduct concurrent and retrospective audits, provide feedback, maintain the audit tracking database, and keep current on regulatory standards while safeguarding member confidentiality.

Qualifications

• Bachelor’s degree in a health or business related field preferred; two years of experience with grievance, appeal, and State Hearing cases or equivalent education/experience.
• Very detail oriented with excellent writing and communication skills.
• General knowledge of managed care and Medi-Cal benefits desired

Responsibilities

• Regular audits of case investigations per established criteria and provide feedback to associates.
• Perform routine quality assurance audits for grievance, appeals, exempts, and State Hearing cases.
• Assess cases for DHCS timelines, NCQA specs, and internal standards.
• Evaluate accuracy of clinical guidance and written communications.
• Maintain audit tracking database and log findings.
• Provide audit feedback to G&A Manager and supervisors.
• Keep current on regulatory requirements affecting G&A audit practices.
• Suggest areas for training and close oversight based on audit results.
• Recommend improvements to enhance accuracy, quality, and reporting of investigations.

Skills

Attention to detail

Writing skills

Communication skills

Organizational skills

Data entry / computer skills

Education

Bachelor’s degree in health or business

Tools

Data systems experience

Computer systems

Job description

Partnership HealthPlan of California is seeking an Internal Auditor within the Grievance & Appeals Department to assess the quality of grievance, appeal, and State Hearing investigations, ensuring DHCS and NCQA requirements are met.

You will conduct concurrent and retrospective audits, provide feedback, maintain the audit tracking database, and keep current on regulatory standards while safeguarding member confidentiality.