Appeals & Grievances QA

Lead I – BPM

 

Who We Are:

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations. Our BPaaS solutions manage complex admin tasks, allowing our customers to prioritize members’ well-being. With our commitment to simplicity, honesty, and leadership, we navigate challenges with our customers to achieve affordable health care for all.

We have a strong global presence and a dedicated workforce of over 4000 people spread across the world.

Our brand is built on the strong foundation of simplicity, integrity, people-centricity, and leadership. We stay inspired in our goal to unburden healthcare and ensure it reaches all, equitably and effectively.

 

You Are:

Perform production and quality audits to ensure operations are effective, consistent and in compliance with business rules and CMS processing standards. Primary focus includes but is not limited to auditing of all functions across Back Office Operations. This auditing activity is essential to support and proactively analyze internal and CMS audit readiness.

 

The Opportunity:

·       Completes quality audits across all functions of Back Office Operations, reviewing completed work in comparison to established documented procedures to determine accuracy.

·       Complies and reports all audit activity and results weekly to leadership team

·       Providers monthly assessment and analysis of audit results

·       Identify training opportunities based on quality assessment results

·       Conducts reviews of DLPs across functional areas for accuracy of information and instruction.

·       Collaborates with each Operations manager to build and execute specific functional audit plans for Claims, Configuration, Appeals and Grievances and Billing and Enrollment functions.

·       Perform audit related investigation to troubleshoot error trends as it relates to business processes and/or training.

·       Coordinates the impact of regulatory changes and updates to policies, practices and procedures and works closely with managers and stakeholders to appropriately translate the updates to the end user.

·       Reviews, evaluates and makes recommendations for process improvements.

·       Assists in the creation of departmental procedures and reference documents.

·       Participates in projects as assigned.

·       May be responsible for researching operational audit best practices and making recommendations for improvement.

·       Maintains confidentiality of all information processed.

 

This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required.

 

What You Need:

·       Bachelor’s degree or equivalent experience. Background in insurance, business or a related field.

·       EXPERIENCE: 3 to 5 years of relevant work experience can be experience working in corporate environment, preferably in health care environment and/or internal audit experience.

·       Experience working in government program (Medicare and Medicaid) preferred or three (3) or more years experience in an insurance organization which provides working knowledge in one or more of the following areas: claims management, underwriting, finance or auditing; insurance education coursework.

·       Certification or progress toward certification in courses focused on but not limited to Quality Auditor, Quality Manager, Six Sigma or other quality designations is highly preferred and encouraged

·       Working knowledge of CMS guidance and business area development procedures, workflows, and rules for multiple states.

·       Excellent analytical skills to identify opportunities for improvement and recommend solutions.

·       Strong analytical and problem-solving skills.

·       Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information, and respond to questions as appropriate.

·       Ability to read, analyze and interpret policy documents, technical, legal and financial information, and procedures manuals.

·       Excellent verbal and written communication skills.

·       Ability to manage multiple projects and meet necessary deadlines.

·       Basic knowledge of computers, spreadsheet software, and word processing and ability to enter accurately 50 WPM.

·       Ability to perform mathematical calculations.

·       Ability to proofread documents for accuracy of spelling, grammar, punctuation and format and edit as necessary.

·       Ability to maintain confidentiality.

·       Ability to create surveys and survey criteria.

·       Completion of industry recognized quality or internal audit certification(s).

·       Advanced knowledge of industry best practices related to sound internal controls and audit techniques.

·       Ability to assist in the development and implementation of policies, practices, and procedures.

 

Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. UST HealthProof provides a reasonable range of compensation for roles that may be hired in various U.S. markets as set forth below.

Role Location: Remote

Compensation Range:   $42,000-$50,000

 

 

Benefits

Full-time, regular employees accrue up to 16 days of paid vacation per year, receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year), 10 paid holidays, and are eligible for paid bereavement leave. They are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance, as well as the following Company-paid benefits: basic life insurance, accidental death and disability insurance, and short- and long-term disability benefits. Regular employees may purchase additional voluntary short-term disability benefits, and participate in a Health Savings Account (HSA) as well as a Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses. Certain regular employees may have the potential for quarterly incentive-based bonuses and or commissions depending on role. Benefits offerings vary in Puerto Rico.

Part-time employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) Retirement Plan with employer matching.

Full-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year) and are eligible to participate in the Company’s 401(k) program with employer matching. They and their dependents residing in the US are eligible for medical, dental, and vision insurance.

Part-time temporary employees receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year).

All US employees who work in a state or locality with more generous paid sick leave benefits than specified here will receive the benefit of those sick leave laws.

What We Believe

At UST HealthProof, we envision a bold future for American healthcare. Our values are the bedrock beliefs our organization holds dear. They not only define what our brand stands for but also serve as a compass guiding every action and decision.

Guiding Principles

These principles illuminate the path of ‘how’ we operate. They detail actions and behaviors we much embody to honor our values and achieve our goals.

·       Simplicity

Simplifying complexity underlines everything we do—this approach is what makes us unique. We come with an open mind and straightforward approach, cutting our way to the core with measurable and actionable insights.

·       Integrity

Integrity is our currency to build relationships. We believe in being open and honest. It is only natural when we have nothing to hide. It demonstrates that we are here to do the right thing, no matter who is watching.

·       People-Centricity

Everything that we do reflects our deep bonds with peers and customers. These aren't mere transactions, but transformational ties. They shape our culture and decisions, affirming that our true value lies in the lives we touch and impact.

·       Leadership

Taking ownership is about taking initiative, being in-charge and driving things to completion. It’s a brave choice to ‘own’ all aspects of our work, ensuring we take full responsibility for everything we handle.

Mission

A future possible only when health plans are free from administrative burdens so they can truly focus on what matters more – their members’ well-being.

Equal Employment Opportunity Statement

UST HealthProof is an Equal Opportunity Employer.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other applicable characteristics protected by law. We will consider qualified applicants with arrest or conviction records in accordance with state and local laws and “fair chance” ordinances.

UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.

 

 

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