Appeals and Grievances Quality Assurance Auditor

Healthfirst

Quality Assurance Auditor conducting internal audits and investigations for Healthfirst. Ensuring compliance with policies, procedures, and quality standards in grievances and appeals.

Posted 4/14/2026full-timeRemote • Connecticut, New Jersey, New York • 🇺🇸 United StatesMid-LevelSenior💰 $58,900 - $80,070 per yearWebsite

About the role

Key responsibilities & impact

Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information.
Analyze errors and determine root causes for appropriate classification, trending, and remediation.
Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance.
Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner.
Present results of investigations to senior staff and prepare written reports concerning investigation activities.
Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
Assist in the development of departmental policies and procedures.

Requirements

What you’ll need

Experience with the investigation, resolution, and reporting of appeal and grievance processes.
Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations).
High School Diploma or GED from an accredited institution.
Associate degree from an accredited institution preferred.
ICD10 certification.
Experience in an Auditing capacity conducting root cause analysis.
Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family.
Experience handling confidential information.

Benefits

Comp & perks

medical, dental and vision coverage
incentive and recognition programs
life insurance
401k contributions

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

quality auditsroot cause analysisdata managementerror classificationprocess improvementinvestigationreport writingdefect identificationoperational efficiencypolicy development

Soft Skills

analytical skillsattention to detailcommunicationproblem-solvingorganizational skillsteam collaborationfeedback deliveryconfidentiality handling

Certifications

ICD10 certificationHigh School DiplomaGEDAssociate degree