Operations Quality Auditor

AmeriHealth Caritas; Philadelphia (Philadelphia County); Hybrid; USD 50,000 - 70,000; Full time

Job summary

A leading health care solutions provider is seeking an Operations Quality Auditor to ensure compliance with quality performance standards. This role involves analyzing claims processing and call handling, along with documenting audit findings. Ideal candidates should have experience in Medicaid environments and be proficient with data management and quality tools. Enjoy a comprehensive benefits package, including flexible work options and health insurance from Day 1.

Benefits

Flexible work solutions including remote options

Paid time off including holidays and volunteer events

Health insurance coverage on Day 1

401(k) plan

Tuition reimbursement

Qualifications

• Minimum 3 years’ claims experience in a Medicaid environment.
• Experience in call center operations and member/provider database maintenance preferred.

Responsibilities

• Identifies system and/or operational issues hindering quality performance.
• Documents audit findings in the appropriate quality tool.
• Provides strategies for resolution and implementation to Management.

Skills

Claims processing knowledge

Problem analysis

Issue identification

Working knowledge of Microsoft Office

Education

High School/GED

Tools

Facets system

Job description

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

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.

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.