The Quality Assurance Auditor is responsible for performing internal quality assurance audits of operational processes for internal employees and outsourced vendors to ensure compliance with policies, procedures, and quality standards. The incumbent will investigate, audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The individual at this level will embody Healthfirst's Culture Drivers through their workplace behavior and works under minimal supervision.
Duties and Responsibilities
- Conduct quality audits of operational processes for internal employees and outsourced vendors, including authorizations, provider claims, pre and post payments, sources of information, incoming/outgoing calls, and pre/post-service appeals.
- Analyze errors and determine root causes for appropriate classification.
- Record/track quality assessment scores and provide reports or feedback to reduce errors and improve processes and performance.
- Review and investigate work to confirm it has been completed according to company standards and meets all regulatory and compliance guidelines.
- Present results of investigations to senior staff and prepare written reports concerning investigation activities.
- Handle specific requests, including processing, tracking, documenting, reporting, and dispersal of findings and recommendations.
- Identify defects and improve departmental performance by supporting quality, operational efficiency, and production goals.
- Assist in the development of departmental policies and procedures; review the efficiency of existing training.
- Meet established time frames and rates of performance for the quality and quantity of work.
- Respond to regulatory or compliance requests for information or audits in a timely and accurate manner.
- Perform additional duties as assigned.
Qualifications
Minimum
- Experience with the investigation, determination, and reporting of operational processes.
- Proficiency in Microsoft Office suite, including Excel (formatting formulas, managing data, filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations), and SharePoint.
- High School Diploma or GED from an accredited institution.
Preferred
- Associate degree from an accredited institution.
- Knowledge of at least two or more lines of business, such as Medicare NY/NJ, Medicaid, Qualified Health Plan, Essential Plan, Child Health Plus, NH Family.
Hiring Range
- Greater New York City Area (NY, NJ, CT residents): $47,403 - $62,400
- All Other Locations (within approved locations): $41,101 - $60,320
How to Apply
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits, such as medical, dental, and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
Equal Opportunity Employer
Applicants and employees are considered for positions and evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
Perks and Benefits
Health and Wellness
- Health Insurance
- Health Reimbursement Account
- Dental Insurance
- Vision Insurance
- Life Insurance
- Short-Term Disability
- Long-Term Disability
- FSA
- HSA
- Fitness Subsidies
- Mental Health Benefits
- Pet Insurance
Parental Benefits
- Birth Parent or Maternity Leave
- Family Support Resources
Work Flexibility
- Remote Work Opportunities
- Hybrid Work Opportunities
Office Life and Perks
- Commuter Benefits Program
- Casual Dress
- Happy Hours
- Company Outings
- Holiday Events
Vacation and Time Off
- Paid Vacation
- Paid Holidays
- Personal/Sick Days
- Volunteer Time Off
Financial and Retirement
- 401(K) With Company Matching
- Performance Bonus
Professional Development
- Internship Program
- Tuition Reimbursement
- Promote From Within
- Access To Online Courses
- Lunch And Learns
- Associate Or Rotational Training Program
- Learning And Development Stipend
Diversity and Inclusion
- Employee Resource Groups (ERG)
- Woman Founded/Led
- Diversity, Equity, And Inclusion Program
Conclusion
In conclusion, the role of a Quality Assurance Auditor at Healthfirst plays a crucial part in maintaining operational excellence and adherence to regulatory standards. Through meticulous audits, root cause analyses, and proactive process improvements, our auditors ensure that internal operations and outsourced vendor processes meet the highest quality benchmarks.
By embodying Healthfirst's Culture Drivers and leveraging advanced analytical tools, our team continuously enhances efficiency and performance. Join us in making a meaningful impact on healthcare quality while enjoying competitive compensation, comprehensive benefits, and a supportive work environment that values diversity, equity, and inclusion.
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