Quality Auditor Lead

Elevance Health • San Juan, PR

1d • Hybrid

About The Position

Quality Auditor Lead Location: Puerto Rico.This role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: This position will work an 8-hour first shift, Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs. Our Puerto Rico location operates a bilingual Spanish and English call center, providing clear and precise answers to customer queries. The Quality Auditor Lead is responsible for examining and evaluating the accuracy of transactions in accordance with regulations and company guidelines.

Requirements

• Requires Associate degree and a minimum 4 years related experience; or any combination of education and experience which would provide an equivalent background.

Nice To Haves

• Fully Bilingual (English & Spanish), Must be able to write, read and speak both languages in a proficiency level.
• Minimum two years of experience in the healthcare industry preferred.
• Minimum two years of experience working with Medicare and Medicaid preferred.
• Strongly prefer experience in trending and analysis of data as well as experience in two or more operational areas.
• Proficient in trending and analysis of data preferred.

Responsibilities

• Identifies documents and reports any transaction errors in a timely manner to ensure prompt resolution.
• Applies expert knowledge in all key areas.
• Able to perform all complex functions while working under minimal direction.
• Examines and evaluates on a prepayment basis the accuracy of transactions processed by reviewing policy, procedure and manual input in accordance with guidelines.
• Tracks and trends audit results and provides feedback to management.
• Generates monthly reports of audit findings and supports clients with issues identified.
• Develops and analyzes reports requested by management.
• Provides cross training and mentorship to quality associates on various products and lines of business.
• Produces other ad hoc reports as requested by internal and external clients.
• Functions as subject matter expert for multiple types of audits, ensuring the implementation and execution of audits, monitoring adherence to the prescribed audit methodologies and documentation, and completing analysis and trending of audit results.
• Interacts regularly with business partners: presenting audit program results, reviewing discrepancies and validating implementation of action plans, managing appeals processes, and performing calibration sessions for various audit scenarios.
• Acts as a leader for the team, providing training and guidance for audit staff, answering questions around audit process or systems that may arise, and filling in with other duties as required.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree