Quality Assurance Manager

WPS—A health solutions company; Town of Florida (NY); À distance; USD 85 000 - 115 000; Plein temps

Avantages offerts par ce poste

Remote work options

Performance bonus

401(k) match

Paid time off

Health insurance

Dental insurance

Telehealth

Professional development

Résumé du poste

WPS, a health solutions company, is seeking a Quality Assurance Manager to oversee QA activities for the Audit and Reimbursement department, specializing in Medicare reimbursement and cost reporting. You will provide technical leadership, monitor quality, and drive continuous improvement in QA processes.

The role emphasizes CMS compliance, risk assessment, and interpretation of Medicare regulations, with remote work options in eligible states and a focus on cross-functional collaboration.

Qualifications

• +Bachelor’s degree in Accounting, Finance, Business Admin or related field or equivalent education/experience.
• +5+ years of Medicare auditing and/or Reimbursement experience.
• +Extensive knowledge of auditing techniques and Government Auditing Standards.
• +Understanding of claims processing and PS&R.
• +Strong researching skills and knowledge of authoritative sources.
• +Expertise in reimbursement methodologies and cost allocation.
• +Analytical, decision-making and judgment abilities.
• +Group facilitation, project management, data analysis and risk assessment.
• +Strong written & verbal communication skills.

Responsabilités

• Coordinate and oversee QA activities for Medicare Audit and Reimbursement.
• Develop rebuttals for issues found during QASP reviews.
• Respond to audit research inquiries and review NAH programs.
• Conduct IQC reviews and report findings.
• Lead quarterly meetings to discuss IQC findings with management and staff.
• Oversee quarterly reopening and appeals reviews.
• Review and test forms for accuracy and compliance.
• Interpret CMS regulations and Medicare reimbursement principles.
• Lead cross-functional work groups on auditing techniques and documentation standards.

Connaissances

Auditing techniques

Government Auditing Standards

Medicare rules & regulations

Claims processing & PS&R

Research skills

Reimbursement methodologies

Cost allocation principles

Analytical, decision making & judgment

Group facilitation & project mgmt

Written & verbal communications

Formation

Bachelor's degree or equivalent

Description du poste

Salary Range $85,000 ~ $115,000

Our Quality Assurance Manager coordinates and oversees the continued development, implementation, and monitoring of the Quality Assurance activities for the Audit and Reimbursement department. They serve as a subject matter expert in Medicare reimbursement and cost reporting, provide technical leadership, monitor quality through periodic reviews, and facilitate ongoing development and implementation of the Quality Assurance process.

This QA Manager ensures adherence to the regulations of the Centers for Medicare and Medicaid Services (CMS). They play a critical role in risk assessment, Medicare regulation interpretation, and continuous improvement initiatives that support responsible stewardship of Medicare funds.

The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, experience, and may fall outside of this pay range.

Work Location

We are open to remote work in the following approved states: Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin

How do I know this opportunity is right for me?

• Enjoy consulting with Management in facilitating the development and implementation of Quality Assurance activities as well as consistency monitoring within Medicare Audit and Reimbursement.
• Like to research and respond to issues by developing rebuttals for each issue found during the annual Quality Assurance Surveillance Plan (QASP) reviews completed for Medicare Administrative Contractor (MAC) contracts (J5 and J8).
• Can respond to audit staff on various audit research issues, perform tertiary review for Nursing and Allied Health (NAH) provider operated programs, and review Organ Acquisition audit scoping.
• Have conducted Internal Quality Control (IQC) reviews and issued an IQC report to Medicare Audit and Reimbursement Management.
• Would like to conduct quarterly meetings with Medicare Audit and Reimbursement Management and Field Audit Supervisors and staff to discuss IQC findings.
• Want to Complete quarterly Reopening and Appeals Reviews ensuring compliance with Medicare regulations.
• Have reviewed and approved forms that are created or revised ensuring the forms are accurate and properly tested.
• Can respond timely and accurately to provider inquiries and inquiries from other internal and external customers.
• Like to interpret and apply CMS regulations, Medicare reimbursement principles, and Government Auditing Standards to complex scenarios.
• Can lead or participate in work groups, special projects, regulatory implementation initiatives, and cross-functional collaborations focused on improving work paper guidelines, auditing techniques, and documentation standards.

Minimum Qualifications

• Bachelor’s degree in Accounting, Finance, Business Administration, or related field, or equivalent post high school education and/or work-related experience.
• 5 or more years of progressive experience in Medicare auditing and/or Reimbursement activity.
• Extensive, thorough knowledge of auditing techniques, practices and issues, Government Auditing Standards and Medicare rules and regulations.
• Thorough knowledge and understanding of claims processing and pricing and the Provider Statistical and Reimbursement Report (PS&R).
• Excellent researching skills and understanding of the types and hierarchy of authoritative sources.
• Demonstrated expertise in complex reimbursement methodologies and cost allocation principles.
• Proven analytical, decision making and judgment abilities.
• Demonstrated skill in group facilitation, project management, data analysis, and risk assessment.
• Strong skills with professional, technical written and verbal communications.

Preferred Qualifications

• 7 or more years of progressive experience in Medicare auditing and/or Reimbursement activity.
• Significant experience with audit methodologies, financial analysis, and regulatory compliance.
• A strong affinity to technical documentation and healthcare writing.

Remote Work Requirements

• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
• Please review Remote Worker FAQs for additional information.

Benefits

• Remote work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS’ culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

This position supports services under Centers for Medicare & Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services