Quality Auditor - Health Plan Operations

SCAN Health Insurance•California, MO

1d•$25 - $37•Remote

About The Position

The Quality Auditor will perform routine and targeted operational quality audits across health plan operations including but not limited to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials to ensure compliance with regulatory requirements, internal policies, contractual obligations, and operational standards. This role monitors quality, accuracy, identifies opportunities for improvements that will enhance member and provider experience.

Requirements

Associate’s degree preferred or equivalent experience
3+ years complex auditing processing and/or auditing experience in the health plan, healthcare, or managed care organization with experience in Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials.
Must be proficient in processing/auditing for Medicare and Medicaid plans.
3+ years’ experience in managed healthcare environment related to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and Letters/Materials processing/audit processing/audit.
Strong organizational, analytical thinking and accounting skills; oral and written communication skills
Strong knowledge of CMS requirements regarding auditing processing
Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience.
Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment.
Strong PC Skills. Microsoft Office (Word, Excel, Outlook, Teams) are required.

Nice To Haves

Curious about AI and its power to transform how we operate and serve our members.

Responsibilities

Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials standards for assigned business process
Work assigned cases through SCANs workflow system, and applies correct status attributes to track and trend issues.
Notate cases/audits with required detail to ensure that others understand status of case/audit and final resolutions.
Work closely with other business units to ensure processing errors are reviewed and corrected
Follow policies and procedures in order to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management; identify and report problems with workflows following proper departmental procedures; actively participate in departmental staff meetings and training sessions.
Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.
Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity and attendance.
Escalate appropriate audit issues to management as required and follow departmental/organizational policies and procedures.
Maintain required levels of production and quality standards as established by management.
Participate in and supports ad-hoc audits as needed.
Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers.
Contribute to team effort by accomplishing related results as needed.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.

Benefits

Base wage range: $25.38 to $36.76 per hour
Annual bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement
An opportunity to become part of a team that makes a difference to our members and our community every day!
A competitive compensation and benefits program
An annual employee bonus program
Generous paid-time-off (PTO)
Eleven paid holidays per year
Excellent Retirement Savings program
A work-life balance