Grievance & Appeals Quality Auditor

Partnership HealthPlan of California; Fairfield (CA); On-site; USD 58,000 - 72,000; Full time

Job summary

Partnership HealthPlan of California is seeking an Internal Auditor for the Grievance & Appeals Department to ensure quality investigations meet DHCS, NCQA requirements and internal standards. The auditor reviews grievance, appeal, exempts, and State Hearing cases and identifies improvements to enhance investigation outcomes.

Responsibilities include conducting concurrent and retrospective audits, providing feedback to associates, ensuring timely quality assurance, and maintaining strict

Qualifications

• Bachelor’s degree in a health or business related field preferred; two (2) years of experience with grievance, appeal, and State Hearing cases or equivalent.
• Experience with medical criteria used to determine approval of medications, services, or referrals desired.
• Very detail oriented with excellent writing and communication skills.

Responsibilities

• Regularly conducts concurrent and retrospective audits of case investigations and provides feedback to associates.
• Performs quality assurance audits for grievance, appeals, exempts, and State Hearing cases.
• Assesses compliance with DHCS timelines, NCQA specifications, and internal standards.
• Evaluates referral appropriateness and ensures accurate use of reporting fields.
• Enters audit findings and communicates feedback to G&A management; maintains confidentiality of PHI/PII.

Skills

Audit

Quality assurance

Regulatory knowledge

Healthcare experience

Education

Bachelor's degree

Job description

Partnership HealthPlan of California is seeking an Internal Auditor for the Grievance & Appeals Department to ensure quality investigations meet DHCS, NCQA requirements and internal standards. The auditor reviews grievance, appeal, exempts, and State Hearing cases and identifies improvements to enhance investigation outcomes.

Responsibilities include conducting concurrent and retrospective audits, providing feedback to associates, ensuring timely quality assurance, and maintaining strict