Quality Auditor/Analyst, Grievance and Appeal

Navitus Health Solutions, LLC•,

6h•$54,236 - $64,567•Remote

About The Position

Navitus is adding a Quality Auditor and Analyst, Grievance and Appeals to evaluate and improve case accuracy among Grievance and Appeals (G&A) Coordinators. The role conducts quality and consistency audits across G&A positions and establishes or maintains audit policies and procedures based on expert knowledge of compliance and regulatory requirements for Medicaid, Medicare, Commercial, and Marketplace programs. In coordination with G&A department leaders, the position assists with or leads department audits conducted by CMS, clients, and state regulatory bodies. It uses established audit tools to conduct and report audits, including quantitative and qualitative analyses, tracks and reports quality metrics, and contributes to monthly and quarterly reporting. The role also coordinates training and retraining, monitors overall work quality, develops training to address knowledge gaps, and helps prepare responses to audit questions and findings in collaboration with internal departments, including Government Programs and Compliance. This is a remote role available only to residents of the states and Washington, DC listed in the posting. The stated schedule is Monday through Friday, 8 a.m. to 5 p.m.

Requirements

Associate or bachelor's degree strongly preferred.
Three to five years of audit, analytical, compliance, reporting, managed care, and/or insurance background preferred.
Strong knowledge of CMS coverage determination and redetermination processes preferred.
Problem-solving skills, including identifying and accepting challenging situations and creating and implementing solutions.
Proficiency in Microsoft Word, Excel, and PowerPoint, including tables, charts, and figures, desired.
Advanced skills with appropriate software programs, databases, and QlikView to organize and trend data and produce documents, charts, and spreadsheets.
Ability to interact cooperatively and respectfully with other employees.
Ability to participate in, adhere to, and support compliance program objectives.

Nice To Haves

Experience with CMS, NCQA, URAC, and/or HHSC audits desired.
Associate or bachelor's degree strongly preferred.
Three to five years of audit, analytical, compliance, reporting, managed care, and/or insurance background preferred.
Strong knowledge of CMS coverage determination and redetermination processes preferred.
Proficiency in Microsoft Word, Excel, and PowerPoint, including tables, charts, and figures, desired.

Responsibilities

Conduct quality and consistency audits of Navitus Grievance and Appeals work.
Develop and provide ongoing training and education for the G&A team.
Prepare and maintain audit policies and procedures.
Assist Grievance and Appeals Coordinators with entry when required.
Develop, follow, and coordinate the audit work plan and ensure timely submission of monthly and quarterly reports.
Mine and assess large amounts of data and compile detailed reports with quantitative and qualitative analyses.
Provide feedback, mentoring, training coordination, and onboarding support for new staff in G&A job functions.
Research best practices and assess program guidelines to maintain quality offerings for clients and members.
Maintain compliance and awareness of current accreditations, including URAC, NCQA, and other regulatory bodies.
Assist or lead department audits conducted by CMS, clients, and state regulatory bodies.
Help prepare responses to audit questions and findings in collaboration with internal departments, including Government Programs and Compliance.
Track and report quality metrics to department leaders.
Contribute to monthly and quarterly reports for appropriate filing and timely submission.
Participate in, adhere to, and support compliance program objectives.
Perform other duties as assigned.