Appeals and Grievances Quality Assurance Auditor
Healthfirst
full-time
Posted on:
Location Type: Remote
Location: Connecticut • New Jersey • United States
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Salary
💰 $58,900 - $80,070 per year
About the role
- 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
- 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
- medical, dental and vision coverage
- incentive and recognition programs
- life insurance
- 401k contributions
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
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