Appeals & Grievances Quality Auditor
About The Position
The Appeals & Grievances Quality Auditor is responsible for conducting routine and targeted audits of appeals and grievances cases, ensuring adherence to applicable federal and state regulations, accreditation standards, organizational policies, and operational procedures. This role evaluates case quality, identifies trends and improvement opportunities, supports corrective action initiatives, and provides reporting, training, and guidance to appeals and grievances leadership. The role supports regulatory readiness, quality improvement initiatives, staff training, and ongoing monitoring activities designed to strengthen compliance, operational effectiveness, and member experience. The ideal candidate possesses strong analytical, auditing, and problem-solving skills, along with a solid understanding of health plan appeals and grievances processes and healthcare regulatory requirements.
Requirements
- Bachelor's degree or equivalent experience in related field
- 5 years of work experience beyond degree working directly in Appeals & Grievances within a health plan environment
Nice To Haves
- Background in processing, reviewing, or auditing Appeals and Grievances cases across one or more lines of business (Medicare, Medicaid, and Commercial).
- Knowledge of Appeals and Grievances regulatory requirements, including CMS, NCQA, state, and accreditation standards.
- Participation in process improvement initiatives focused on operational efficiency, regulatory compliance, and member experience.
- Ability to develop, implement, and maintain audit best practices, quality standards, and operational controls.
- Demonstrated success providing coaching, consultation, and quality-related feedback to leaders and operational staff.
Responsibilities
- Conduct routine and targeted audits of appeals and grievances cases to evaluate compliance with regulatory, accreditation, and organizational requirements.
- Review case documentation, determinations, correspondence, timeliness, and procedural accuracy.
- Monitor compliance with established turnaround times, notification requirements, and documentation standards.
- Analyze audit results to identify trends, root causes, compliance risks, and opportunities for improvement.
- Prepare and distribute audit reports, dashboards, scorecards, and quality metrics.
- Track quality performance indicators and provide recommendations to improve outcomes and reduce risk to leadership.
- Support the development of monitoring plans and quality assurance strategies.
- Partner with leadership to address audit findings and implement corrective action plans.
- Participate in quality improvement initiatives focused on compliance, efficiency, and member experience.
- Recommend enhancements to workflows, policies, procedures, training materials, and job aids.
- Support readiness activities for internal audits, regulatory reviews, and accreditation surveys.
- Provide coaching and feedback to leadership regarding audit results and quality expectations.
- Assist with the development and delivery of quality, compliance, and process-related training.
- Serve as a resource on appeals and grievances quality standards, regulatory requirements, and best practices.
- Participate in special projects and other departmental initiatives as assigned.
Benefits
- competitive medical, dental, vision, PTO, Holidays, paid volunteer time off, 401K contributions, caregiver services
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
