QA Auditor, Appeals and Grievances

Healthfirst; Pennsylvania; On-site; USD 50,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated QA Auditor to ensure compliance and quality standards in the appeals and grievances process. This full-time role involves conducting audits, analyzing errors, and presenting findings to senior staff. The ideal candidate will have a strong background in investigation and resolution, along with proficiency in Microsoft Office applications. Join a dynamic team that values quality and compliance in the healthcare sector, and contribute to improving operational processes while embodying the company’s culture of excellence.

Benefits

Medical insurance

Dental insurance

Vision insurance

401k plan

Qualifications

• Experience in investigating and resolving appeals and grievances.
• Proficient in Microsoft Office applications.

Responsibilities

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

Skills

Investigation of appeals and grievances

Root cause analysis

Microsoft Office proficiency

Education

High School Diploma or GED

Associate degree

Tools

Microsoft Excel

Microsoft Word

Microsoft PowerPoint

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 workplace behavior and works under minimal supervision.

Responsibilities include:

1. Conduct quality audits of A&G items including grievances, pre-service appeals, and post-service appeals utilizing appropriate sources of information; analyze errors and determine root causes for classification, trending, and remediation.
2. Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance.
3. Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
4. Present results of investigations to senior staff and prepare written reports.
5. Handle follow-up audits and processing of specific appeal and grievance requests, including tracking, documenting, and reporting findings and recommendations.
6. Identify defects and support departmental performance improvements.
7. Assist in developing departmental policies and reviewing training efficiency.
8. Meet performance time frames and quality standards.
9. Participate in regulatory and mock audits, including universe review, risk analysis, and case walkthroughs.
10. Perform additional duties as assigned.

Minimum Qualifications:

• Experience with investigation, resolution, and reporting of appeal and grievance processes.
• Proficiency in Microsoft Office applications, including Excel, Word, and PowerPoint.
• High School Diploma or GED from an accredited institution.

Preferred Qualifications:

• Associate degree from an accredited institution.
• ICD10 certification.
• Experience in auditing and root cause analysis.
• Knowledge of multiple lines of business such as Medicare NY/NJ, Medicaid, etc.
• Experience handling confidential information.
• Knowledge of regulatory requirements for appeals and grievances.

Additional Details:

Salary ranges vary by location, with specific figures provided for the Greater New York City Area and other locations. Benefits include medical, dental, vision, life insurance, 401k, and more. The role is full-time, with employment in the healthcare industry.