QA Auditor, Appeals and Grievances

Healthfirst; New York (NY); On-site; USD 57,000 - 77,000; Full time

Job summary

An established industry player seeks a dedicated QA Auditor for Appeals and Grievances. This role involves conducting internal quality audits, analyzing operational processes, and ensuring compliance with policies and standards. You will investigate and resolve appeals and grievances while providing insights to improve departmental performance. The ideal candidate will have a strong background in quality assurance and be proficient in Microsoft Office applications. Join a forward-thinking organization that values quality and operational efficiency, offering a competitive salary and comprehensive benefits package.

Benefits

Medical coverage

Dental coverage

Vision coverage

Life insurance

401k contributions

Incentive programs

Recognition programs

Qualifications

• Experience with investigation and resolution of appeal and grievance processes.
• Knowledge of state and federal appeal and grievance regulatory requirements.

Responsibilities

• Conduct quality audits of appeals and grievances to ensure compliance.
• Analyze errors and determine root causes for remediation.

Skills

Investigation of appeal and grievance processes

Microsoft Excel

Microsoft Word

Microsoft PowerPoint

Root cause analysis

Regulatory compliance knowledge

Education

High School Diploma or GED

Associate degree

Tools

Microsoft Office Suite

Job description

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The Quality Assurance Auditor is responsible for performing Internal Quality Assurance Audits of Operational processes for internal employees and outsourced vendors to ensure compliance with policies, procedures and quality standards. The incumbent will investigate, audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The individual at this level will embody Healthfirst’s Culture Drivers through his/her workplace behavior and works under minimal supervision.

• Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request. Analyze errors and determine root causes for appropriate classification, trending, and remediation.
• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.
• Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
• Present results of investigations to senior staff and prepare written reports concerning investigation activities.
• Subsequent auditing and handling of specific appeal and grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
• Assist in the development of departmental policies and procedures; reviews the efficiency of existing training.
• Meet established time frames and rates of performance for the quality and quantity of work for the position.
• Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities
• Additional duties as assigned
  
  

Minimum Qualifications

• Experience with the investigation, resolution, and reporting of appeal and grievance processes.
• Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations).
• High School Diploma or GED from an accredited institution
  
  

Preferred Qualifications

• Associate degree from an accredited institution.
• ICD10 certification
• Experience in an Auditing capacity conducting root cause analysis
• Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family
• Experience handling confidential information.
• Compliance & Regulatory Responsibilities: Knowledge of state and federal appeal and grievance regulatory requirements
• License/Certification: NA
  
  
  
  

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $57,408 - $76,960
• All Other Locations (within approved locations): $49,795 - $72,800
  
  

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Quality Assurance

• Industries

  Hospitals and Health Care

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