Remote Enrollment Quality Auditor: Medicaid/MLTC

HealthEdge Software, Inc.; Northern (KY); Hybrid; USD 44,000 - 50,000; Full time

Job summary

HealthEdge Software, Inc. is seeking an Enrollment Quality Auditor to join our UST HealthProof team.

You will perform audits of enrollment transactions for a specific customer, ensuring accuracy of dates, eligibility, and plan changes while coordinating with state systems and enrollment brokers. This full-time remote position requires a High School Diploma and 3+ years of auditing experience in Medicaid enrollment; proficiency with MS Office; and familiarity with HealthRules Payor or

Qualifications

• High School Diploma or GED required.
• 3 years health plan enrollment/eligibility auditing operations experience required.
• Medicaid MLTC or dual-eligible enrollment experience strongly preferred.
• Proficiency in MS Suite, specifically Excel, PowerPoint and Outlook.
• HealthRules Payor or GuidingCare experience preferred; familiarity with EDI 834 enrollment transactions a plus.
• Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness.
• Ability to effectively communicate and collaborate with a remote team.

Responsibilities

• Audit enrollment, disenrollment, eligibility, and plan/PCP change transactions for a specific customer.
• Be responsible for following the customer quality process and tools for audit and rebuttal process.
• Review enrollment (834) file transactions and coordination with state enrollment systems and enrollment brokers to confirm accuracy of member effective dates, retroactive enrollment/disenrollment, and eligibility segments.
• Verify timely and accurate processing of Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards.
• Audit dual-eligible enrollment coordination, including alignment of Medicare and Medicaid eligibility segments.
• Share QA results with individual associates, coordinate with operational Team Leads and managers to provide feedback to individuals.
• Collate, compile and report QA performance to management and individuals.
• Provide inputs to the Training team and Team Leads for up-to-date written processing instructions and refresher training needs.
• Participate in Audit the Auditor program.
• Participate in semi-annual or annual auditor calibration activities.
• Maintain currency on CMS Medicaid guidelines and MLTC enrollment requirements.

Skills

Enrollment auditing

MS Excel

MS PowerPoint

MS Outlook

Remote collaboration

Data analysis

Healthcare payer

Education

High School Diploma or GED

Tools

HealthRules Payor

GuidingCare

EDI 834 systems

Job description

HealthEdge Software, Inc. is seeking an Enrollment Quality Auditor to join our UST HealthProof team.

You will perform audits of enrollment transactions for a specific customer, ensuring accuracy of dates, eligibility, and plan changes while coordinating with state systems and enrollment brokers. This full-time remote position requires a High School Diploma and 3+ years of auditing experience in Medicaid enrollment; proficiency with MS Office; and familiarity with HealthRules Payor or