Senior Quality Verification Specialist

Gainwell Technologies LLC•Any city, OH

12d•$63,000 - $90,000•Remote

About The Position

The Senior Quality Verification Specialist protects member and provider information through independent, second-level quality reviews using an “audit-the-auditor” approach. The role reassesses completed verification reviews and independently retests underlying evidence, controls, decisions, and handoffs across the request lifecycle, including intake, authentication, verification, approval, processing, communication, escalation, and closure. The scope includes member and provider account access requests, portal administrator access changes, and provider Electronic Funds Transfer (EFT) change requests. The specialist conducts independent quality and compliance reviews to ensure requests are handled accurately, securely, and in accordance with established procedures, confidentiality requirements, and conflict-of-interest standards. Working with Compliance, Operations, Quality, Privacy, Security, and other authorized stakeholders, the specialist evaluates end-to-end processing, documents findings, validates corrective actions, and confirms sustained improvements. The position provides objective reporting, risk identification, and compliance guidance while remaining independent from operational decision-making. Reviews must remain within delegated authority, and cases in which the reviewer was directly involved must be reassigned to an independent reviewer for evaluation and closure validation. This role also contributes to operational improvement by translating findings and trends into recommendations for training, procedures, workflows, system enhancements, automation, and controls. It provides evidence-based coaching and knowledge sharing, supports approved verification and operational activities, and preserves review independence when conducting those activities.

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 the ability to prepare findings reports, present results and risk-based recommendations, guide and coach Verification Specialists, promote consistent review standards, and partner on improvements.
Proficiency with Microsoft Office and SharePoint.
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 changes, 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 recommendations for people, process, or technology improvements.
Familiarity with CXone or comparable interaction-review platforms, member and provider systems of record, and business-verification tools.

Responsibilities

Independently reassess completed verification reviews for completeness, accuracy, consistency, and appropriateness of prior reviews, findings, decisions, and escalations.
Apply random, risk-based, targeted, and retrospective review methodologies, retesting controls, documentation, decisions, and handoffs against requirements in effect at the time of processing.
Retest verification controls for identity, representative authority, affiliation, and ownership requirements; validate authentication procedures, protection of verification responses, call controls, scripts, disclosures, and documentation standards.
Assess member and provider interactions involving account access requests and provider EFT changes, including accuracy, professional communication, authorized representative handling, documentation, escalation, and follow-up.
Test high-risk request controls, including request completeness, supporting evidence, signatures, organizational relationships, email and website validations, banking information, ownership, authorized exceptions, and portal access administration.
Document review scope, sampling methods, findings, risks, severity, rationale, and recommendations in clear, evidence-based reports, and present results to compliance leadership, business leaders, and process owners.
Immediately escalate critical risks, including suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and significant compliance issues.
Track remediation, support root-cause analysis, confirm corrective-action effectiveness, and escalate overdue or ineffective actions.
Maintain complete and traceable review evidence connected to original case documentation while following retention, access, and legal hold requirements.
Translate trends and findings into recommendations for training, procedures, workflows, system enhancements, automation opportunities, and control improvements.
Provide evidence-based coaching, support onboarding and knowledge sharing, identify training needs, and recommend updates to procedures, scripts, checklists, and reference materials.
Support authorized operational work through approved verification activities, member and provider follow-up, and operational support while maintaining separation from reviews of the same cases.
Maintain objectivity, avoid conflicts of interest, and route cases personally performed or materially influenced to an independent reviewer for reassessment or closure validation.
Collaborate with Compliance, Operations, Quality, Privacy, Security, and other authorized stakeholders to strengthen controls, processes, and organizational performance.