QA Auditor, Quality Assurance

Job Description: • Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request. • 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 to ensure quality. • 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. • Subsequent auditing and handling of specific appeal and grievance requests including processing where applicable, 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; reviews the efficiency of existing training. • Meet established time frames and rates of performance for the quality and quantity of work for the position. • Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities. 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 (preferred). • Experience in an Auditing capacity conducting root cause analysis (preferred). • Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family (preferred). • Experience handling confidential information. Benefits: • medical, dental and vision coverage • incentive and recognition programs • life insurance • 401k contributions Apply tot his job