Operations Quality Auditor

AmeriHealth Caritas; Philadelphia (Philadelphia County); Hybrid; USD 45,000 - 65,000; Full time

Job summary

AmeriHealth Caritas is looking for an Operations Quality Auditor to ensure quality standards in various operations, including claims processing and call handling. This role requires at least 3 years of experience in a Medicaid environment, focusing on identifying and resolving operational issues.

Benefits

Flexible work solutions including remote options

Competitive pay

Paid time off including holidays and volunteer events

Health insurance coverage for dependents on Day 1

401(k) Tuition reimbursement

Qualifications

• Minimum 3 years’ claims experience in a Medicaid environment.
• Claims processing knowledge required.
• Working knowledge of Microsoft Office applications.

Responsibilities

• Review of claims processing, call handling, and member/provider data maintenance.
• Identify system issues affecting quality performance standards.
• Document audit findings accurately.

Skills

Claims processing knowledge

Problem analysis

Documentation

Microsoft Office

Education

High School/GED

Tools

Facets system

Job description

Your career starts now. We're looking for the next generation of health care leaders.

At AmeriHealth Caritas, we're passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we'd like to hear from you.

Headquartered in Newtown Square, PA, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Role Overview:

Under the direct supervision of the Supervisor, Manager, and/or Director of Operations Quality Auditing, the Operations Quality Auditor is responsible for the timely and accurate review of various tasks performed by Operations (including, but not limited to, claims processing, call handling, and member/provider data maintenance).

Responsibilities:

• Identifies system and/or operational issues hindering the attainment of quality performance standards as defined by AMFC policy and associated business rules
• Provides issue identification, problem analysis, and strategies for resolution and/or implementation to Management
• Accurately documents audit findings in the appropriate quality tool

Education and Experience:

• High School/GED required
• Minimum 3 years’ claims experience in a Medicaid environment
• Claims processing knowledge required, preferably with the Facets system
• Working knowledge of Microsoft Office applications
• Experience in call center operations and member/provider database maintenance preferred

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.