RESPONSIBILITIES:

Completes quality audits across all functions of Back Office Operations, reviewing completed work in comparison to established documented procedures to determine accuracy Compiles and reports all audit activity and results weekly to leadership team Provides monthly assessment and analysis of audit results Identifies 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 Performs 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

 

REQUIREMENTS:

3 to 5 years of relevant work experience in healthcare, including experience in Medicare and Medicaid; or experience in insurance, claims management, or underwriting Certification or progress toward certification in courses focused on but not limited to quality auditing Six Sigma certification or other quality designations a strong advantage 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 Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information, and respond to questions as appropriate