Quality Auditor Jobs

About The Position

Requirements

• High school diploma or GED.
• Three years of health plan enrollment or eligibility auditing operations experience.
• Proficiency with Microsoft Office Suite, specifically Excel, PowerPoint, and Outlook.
• Ability to analyze contractual SLAs and KPIs, particularly those concerning enrollment processing timeliness.
• Ability to communicate and collaborate effectively with a remote team.

Nice To Haves

• Medicaid managed care enrollment auditing experience.
• Managed long-term care (MLTC) or dual-eligible Medicare-Medicaid enrollment experience.
• HealthRules Payor or GuidingCare experience.
• Familiarity with EDI 834 enrollment transactions and eligibility verification systems.

Responsibilities

• Audit enrollment, disenrollment, eligibility, and plan or PCP change transactions processed by health plan enrollment associates for a specific customer.
• Follow the customer’s quality process and tools for audits and rebuttals.
• Review 834 enrollment file transactions and coordinate with state enrollment systems and enrollment brokers to confirm member effective dates, retroactive enrollment or disenrollment, and eligibility segments.
• Verify timely and accurate processing of Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards.
• Audit dual-eligible Medicare-Medicaid enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits.
• Share QA results with individual associates and coordinate feedback with operational Team Leads and managers, clearly identifying errors and opportunities for improvement.
• Compile and report team and individual associate QA performance to management and individuals.
• Provide input to the Training team and Team Leads for current written processing instructions and refresher training needs.
• Participate in the company’s or customer’s Audit the Auditor program.
• Participate in semi-annual or annual auditor calibration activities.
• Maintain currency on CMS Medicaid managed care enrollment guidelines, applicable state Medicaid enrollment requirements, and managed long-term care enrollment and disenrollment rules.