QA Auditor, Appeals and Grievances

Healthfirst; United States; Remote; USD 49,000 - 77,000; Full time

Job summary

An established industry player is seeking a Quality Assurance Auditor to enhance operational processes and ensure compliance with quality standards. This role involves conducting internal audits, analyzing grievances, and presenting findings to senior staff. The ideal candidate will have strong investigative skills, a background in auditing, and proficiency in Microsoft Office applications. Join a dynamic team dedicated to improving healthcare services and making a significant impact in the industry. If you're passionate about quality assurance and compliance, this is an exciting opportunity to advance your career in a supportive environment.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401k Plan

Recognition Programs

Qualifications

• Experience with investigation and resolution of appeal and grievance processes.
• Proficiency in Microsoft Office applications, especially Excel.

Responsibilities

• Conduct quality audits of appeals and grievances, analyzing errors and root causes.
• Track quality assessment scores and provide feedback to improve processes.

Skills

Investigation and resolution of appeals

Root cause analysis

Microsoft Excel

Microsoft Word

Microsoft PowerPoint

Education

High School Diploma or GED

Associate degree

Tools

Microsoft Office

Job description

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 their workplace behavior and work under minimal supervision.

Responsibilities

1. 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.
2. Record and track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.
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 concerning investigation activities.
5. Handle subsequent audits and processing of specific appeal and grievance requests, including tracking, documenting, reporting, and dispersal of findings and recommendations.
6. Identify defects and support departmental performance improvements by enhancing quality, operational efficiency, and productivity.
7. Assist in developing departmental policies and procedures; review the efficiency of existing training programs.
8. Meet established time frames and performance rates for quality and quantity of work.
9. Participate in regulatory and mock audit activities, including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities.
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 (formulas, data management, filtering), Word (document creation/editing), and PowerPoint (presentation creation/editing).
• High School Diploma or GED from an accredited institution.

Preferred Qualifications

• Associate degree from an accredited institution.
• ICD10 certification.
• Experience in auditing, including root cause analysis.
• Knowledge of at least two lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family.
• Experience handling confidential information.
• Knowledge of state and federal appeal and grievance regulatory requirements.

Additional Information

We are an equal opportunity employer. We comply with all applicable laws and regulations. Applicants and employees are evaluated without regard to race, color, creed, religion, sex, national origin, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender identity/expression, military/veteran status, citizenship, immigration status, height, weight, familial/marital status, or unemployment status, among others.

If you require a reasonable accommodation under the Americans with Disabilities Act or similar law, please contact us via email at [e-mail] or call 212-519-1798 with a description of the accommodation and the position.

Salary Range

• Greater NYC Area (NY, NJ, CT): $57,408 - $76,960
• Other locations within approved areas: $49,795 - $72,800

Your salary will depend on your experience, education, licenses, certifications, and other relevant factors. We also offer benefits including medical, dental, vision, life insurance, 401k, and recognition programs.

About Healthfirst

Healthfirst provides access to a large network of providers and comprehensive healthcare services. Learn more about us.