Senior Quality Verification Specialist

Gainwell Technologies LLC•Any city, OH

3d•$63,000 - $90,000•Remote

About The Position

The Senior Quality Verification Specialist independently evaluates the quality, accuracy, completeness, and compliance of completed member and provider verification reviews using an “audit-the-auditor” approach. The role reassesses evidence, controls, decisions, and handoffs across account access requests—including portal administrator access changes—and provider Electronic Funds Transfer (EFT) change requests. It helps protect member and provider information and ensures requests are processed securely, accurately, and in accordance with established procedures, confidentiality requirements, and conflict-of-interest standards. The position applies random, risk-based, targeted, and retrospective review methods; tests underlying controls; documents evidence-based findings; reports risks and recommendations; and escalates critical issues. Working with Compliance, Operations, Quality, Privacy, Security, and other authorized stakeholders, the specialist validates corrective actions and sustained improvements, supports root-cause analysis, and translates trends into people, process, and technology improvements. The role also coaches Verification Specialists and may support approved operational verification work, while maintaining independence from reviews of cases the specialist performed or materially influenced. The role is fully remote from most U.S. locations and territories. The annual pay range is $63,000 to $90,000, with the offered base pay varying based on factors including geography, internal equity, job-related knowledge, skills, and experience.

Requirements

Five or more years of experience in member services, member or provider verification, provider enrollment, healthcare operations, compliance operations, or a related field, including quality reviews or operational control testing across multi-step workflows.
Ability to apply policies and procedures, independently reassess completed verification reviews, retest controls and handoffs across account access and provider EFT change-request workflows, reconcile conflicting information, and document objective, evidence-based conclusions.
Working knowledge of member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and cross-team handoffs.
Strong analytical, organizational, and time-management skills to prioritize high-risk work and meet quality and turnaround requirements.
Clear written and verbal communication skills, including preparing findings reports, presenting results and recommendations, guiding and coaching Verification Specialists, promoting consistent review standards, and partnering on improvements.
Proficiency with Microsoft Office and SharePoint, and ability to use case-management systems, approved records repositories, and interaction-recording or quality-review platforms.

Nice To Haves

Experience in Medicaid member services or provider operations.
Experience reviewing member and provider interactions involving account access and provider EFT change requests, or conducting end-to-end reviews of EFT, portal administrator access, or other high-risk provider changes.
Experience with independent second-level quality reviews, risk-based sampling across roles and process stages, finding classification, root-cause analysis, corrective-action validation, cross-functional trend reporting, and improvement recommendations.
Familiarity with CXone or comparable interaction-review platforms, member and provider systems of record, and business-verification tools.

Responsibilities

Independently reassess completed verification reviews to evaluate prior review completeness, accuracy, consistency, findings, decisions, and escalations.
Apply random, risk-based, targeted, and retrospective review methods, retesting controls, documentation, decisions, and handoffs against the requirements in effect when a case was processed.
Retest identity, representative authority, affiliation, ownership, authentication, verification-response protection, call controls, scripts, disclosures, and documentation controls.
Assess member and provider interactions related to account access requests and provider EFT changes, including communication, authorized representative handling, information accuracy, documentation, escalation, and follow-up.
Evaluate high-risk request controls, including request completeness, evidence, signatures, organizational relationships, email and website validations, banking and ownership verification, authorized exceptions, and portal access administration.
Document review scope, sampling methods, evidence, findings, risks, severity, rationale, and recommendations in clear, evidence-based reports.
Present review results and risk-based recommendations to compliance leadership, business leaders, and process owners.
Immediately escalate suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and other significant compliance issues according to established procedures.
Track remediation, support root-cause analysis, validate corrective-action effectiveness, and escalate overdue or ineffective actions.
Maintain complete, traceable review evidence tied to original case documentation and follow retention, access, and legal-hold requirements.
Translate trends and findings into recommendations for training, procedures, workflows, system enhancements, automation, and control improvements.
Coach colleagues, support onboarding and knowledge sharing, identify training needs, and recommend updates to procedures, scripts, checklists, and reference materials.
Support authorized operational verification activities and member and provider follow-up while keeping operational work separate from reviews of the same cases.
Maintain objective, independent review practices and route cases personally performed or materially influenced to another independent reviewer for reassessment or closure validation.