Quality Assurance Specialist

GEHA Health; United States; Hybrid; USD 48,000 - 67,000; Full time

Benefits offered by this job

Health/Dental/Vision benefits

401(k) company match

Paid Time Off

Well-being program

Tuition Assistance

Life and AD&D insurance

Short-Term & Long-Term Disability

Job summary

GEHA Health is seeking a Quality Assurance Specialist to audit claims coding, provider interactions, and electronic files for accuracy and compliance. The role involves credentialing and provider relations audits, plus cross-functional collaboration to improve workflows and training materials.

The position requires an associate's degree or equivalent experience, plus 4 years in a related role, with strong communication and MS Excel/Word proficiency. Hybrid/work-from-home options are available.

Qualifications

• Requires an associate's degree (or equivalent experience).
• Requires effective written and verbal communication skills.
• Proficiency with MS Word and MS Excel.
• Thorough knowledge of Provider Data Management policy and procedures.

Responsibilities

• Updates and completes daily, monthly, and annual reports.
• Prepares responses to correspondence and manages complex provider issues and calls.
• Answers questions from PDM staff and other departments regarding provider updates and issues.
• Makes recommendations to improve quality, workflow processes, policies, and procedures.
• Credentialing: Audits and verifications as listed (SAL Audit, WAP Audit, OGM Invalid License, IH Initial & Re-Creds, Cred Verification, MS Review Audit, Contract Audit).
• Provider Relations: Call Audits, Service Issue Audit, Case Audit, Audit Errors; assist with department training.

Education

Associate degree

Tools

MS Word

MS Excel

Job description

Government Employees Health Association, Inc. (G.E.H.A) is a nonprofit member association that provides health and dental benefits that millions of federal employees and retirees, military retirees and their families have counted on since 1937. Offering one of the largest health and dental benefit provider networks available to federal employees in the United States, G.E.H.A empowers health and wellness by meeting its members where they are, when they need care.

G.E.H.A has one mission: To empower federal workers to be healthy and well.

The Quality Assurance Specialist audits claims coding, customer service calls or electronic files for accuracy, benefit payment, contract interpretation, and compliance with policies and procedures.

SKILLS

Duties and Responsibilities

• Updates and completes daily, monthly, and annual reports.
• Prepares responses to correspondence and manages complex provider issues and calls.
• Answers questions from PDM staff and other departments regarding provider updates and issues.
• Makes recommendations to improve quality, workflow processes, policies, and procedures.
• Credentialing:
• SAL Audit
• WAP Audit
• OGM Invalid License
• IH Initial & Re-Creds
• Cred Verification
• MS Review Audit
• Contract Audit
• Provider Relations:
• Call Audits
• Service Issue Audit
• Case Audit
• Audit Errors
• Assists with department training.
• Contributes independently and collaboratively across departments and cross-functional projects.
• Analyzes audit reports and rebuttals to identify trends and recommend determination of outcome.
• Reviews and makes suggestions for changes/updates to training materials and existing desk-level procedures and policies.

Knowledge, Skills, and Abilities

• Requires an associate's degree. Will consider additional experience in lieu of degree.
• Requires 4 years of related experience.
• Requires effective written and verbal communication skills to answer questions from staff and providers.
• Requires proficiency with MS Word and MS Excel.
• Must have thorough knowledge of Provider Data Management policy and procedures.

Preferred Qualifications

• Experience as an Associate Quality Assurance Specialist within PDM.

Work-at-home requirements

• Must have the ability to provide a non-cellular High Speed Internet Service such as Fiber, DSL, or cable Modems for a home office.
• A minimum standard speed for optimal performance of 30x5 (30mpbs download x 5mpbs upload) is required.
• Latency (ping) response time lower than 80 ms
• Hotspots, satellite and wireless internet service is NOT allowed for this role.
• A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

How we value you

• Competitive pay/salary ranges
• Incentive plan
• Health/Vision/Dental benefits effective day one
• 401(k) retirement plan: company match – dollar for dollar up to 4% employee contribution (pretax or Roth options) plus a 6% annual company contribution
• Robust employee well-being program
• Paid Time Off
• Personal Community Enrichment Time
• Company-provided Basic Life and AD&D
• Company-provided Short-Term & Long-Term Disability
• Tuition Assistance Program

Please note that the salary information is a general guideline only. G.E.H.A considers factors such as (but not limited to) scope and responsibilities of the position, candidate’s work experience, education/training, key skills, internal peer equity, as well as, market and business considerations when extending an offer.

The target hiring range for this position is $47,808 - $60,480 USD. At G.E.H.A, the current maximum salary for this role is $67,392 USD. While initial compensation may vary based on experience and qualifications, there is a path to work toward this top rate through performance and continued growth within the organization.

G.E.H.A is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. G.E.H.A will not discriminate against employees or applicants because they have inquired about, discussed, or disclosed their compensation or the compensation of another employee or applicant. We are committed to creating an inclusive environment for all employees. Our diversity drives innovation deepens connections and strengthens our organization.

G.E.H.A is headquartered in Lee's Summit, Missouri, in the Kansas City area. We recognize the importance of balance and flexibility and offer hybrid and work-from-home options for many of our roles.