Quality Auditor - Health Plan Operations
Core
Perform routine and targeted operational quality audits across health plan operations including Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data, and Letters/Materials to ensure compliance and identify improvement opportunities.
Role type
Quality Auditor (Health Plan Operations)
Builds
Compliance reports, audit findings, and process improvement recommendations for Medicare/Medicaid plans.
Domain
Healthcare / Managed Care / Health Insurance
Deliverable
dashboards & analysis
Required skills
Auditing, Claims processing, Grievances and Appeals handling, Enrollment management, Configuration management, Provider Data management, Medicare plan auditing, Medicaid plan auditing, CMS regulatory knowledge, Medical terminology, Microsoft Office (Word, Excel, Outlook, Teams), Analytical thinking, Accounting skills
Preferred skills
Associate's degree, Health insurance training completion
Technologies
Microsoft Office Suite (Word, Excel, Outlook, Teams), SCAN workflow system
Responsibilities
Utilize strong working knowledge of assigned business process standards to ensure regulatory compliance; Work assigned cases through workflow system applying correct status attributes; Collaborate with business units to review and correct processing errors; Follow policies and procedures to maintain efficient operations; Report workflow problems and participate in staff meetings; Maintain required production and quality standards; Escalate audit issues to management as required.
Seniority
Mid-level, hands-on IC