Description and Requirements
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 his/her workplace behavior and works under minimal supervision.
Duties and Responsibilities Include:
- Conduct quality audits of Operational processes for internal employees and outsourced vendors such as authorizations, provider claims, pre and post payments, sources of information, incoming/ outgoing calls, pre/post-service appeals, etc.
- Analyze errors and determine root causes for appropriate classification
- Record/track quality assessment scores and provide reports or feedback to reduce errors and improve processes and performance
- Review and investigate work to confirm it has been completed according to company standards and meets all regulatory and compliance guidelines
- Present results of investigations to senior staff and prepare written reports concerning investigation activities
- Subsequent auditing and handling of specific requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
- Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals
- Assist in the development of departmental policies and procedures; review the efficiency of existing training
- Meet established time frames and rates of performance for the quality and quantity of work for the position
- Respond to any regulatory or compliance requests for information or audits in a timely and accurate manner
- Additional duties as assigned
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Minimum Qualifications:
- Experience with the investigation, determination and reporting of operational processes
- Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations) and SharePoint
- High School Diploma or GED from an accredited institution
Preferred Qualifications:
- Associate degree from an accredited institution.
- Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Qualified Health Plan, Essential Plan, Child Health Plus, NH Family.
Hiring Range:
- Greater New York City Area (NY, NJ, CT residents): $47,403 - $62,400
- All Other Locations (within approved locations): $41,101 - $60,320
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.