The Quality Auditor is responsible for completing internal or external audits and operational quality reviews. This role may be involved in other auditing functions including any focused audit projects assigned. This position will provide documentation of their work and assistance with resolution.
Duties and Responsibilities:
- Audit all internal processes including, but not limited to: Claims, Customer Service interactions, and Enrollment and Billing transactions for financial, procedural and/or payment accuracy for health claims as well as vendor oversight as defined in vendor agreement.
- Assist with identification and development of any process gaps/deficiencies identified, including recommendations to support error resolution, best practice, and quality improvement initiatives.
- Document results of reviews; include recommendations for process improvement and/or training as required.
- Complete assigned audits accurately and timely; maintain audit documentation /results in approved format.
- Participate in quality calibrations to ensure consistency in results and application of policy, procedures, and guidelines.
- Assist in system configuration activities such as triage of newly reported issues; work with users to understand any points of clarification and have a sound understanding on when to escalate items that have critical impact on the business.
- Review and implement methods to ensure receipt of data required for trending and reporting of various quality improvement work plan metrics; perform adequate data/barrier analysis, develop improvement recommendations, and deploy actions as approved.
- Conduct external Vendor reviews as required.
- Complete any special projects and/or focused audits as directed.
Required Knowledge, Skills and Abilities:
- HS Diploma or equivalent, Associates Degree preferred.
- 1+ years of audit experience in the Health Insurance Industry, including HIPAA and ERISA knowledge required.
- 1+ years healthcare claims experience.