Quality Assurance Auditor

Overview

The Quality Assurance Auditor will perform monitoring, oversight, and quality assurance reviews and audits of all lines of business as defined by CMS, NYS DOH, NYS DFS and any/all policies and procedures for assigned operational areas. They will ensure the quality and accuracy of systems and processes that support the organization’s operation to meet client government regulatory requirements and compliance plans, and to assess the effectiveness of services provided.

They will track issues identified during the quality assurance process to ensure resolution, analyze, document, and report results to stakeholders, and collaborate with the QA team and cross-functional teams to remediate audit findings and improve testing and audit strategies, techniques, activities, policies and procedures. Occasional evenings, weekends and holidays will be required.

• High school diploma or GED required;
  Associate’s degree preferred.
• Three (3) years of experience in quality assurance/quality control, compliance monitoring, pharmaceutical or managed care environment.
• Experience with Medicare, Medicaid or another government program strongly preferred.
• Experience with pharmacy on-line claims processing systems preferred.
• Strong analytical, problem solving, time management and organizational skills.
• Ability to use independent judgment and solid reasoning skills when rendering decisions and troubleshooting issues.
• Detail oriented, while maintaining an awareness of overall goals.
• Experience with AS400 query or other query tools.
• Ability to easily learn new software applications.
• Experience in report production.
• Ability to maximize use of system capabilities to lead the organization in outcome improvement.
• Excellent interpersonal, written and verbal communication skills.
• Proven examples of displaying PBD values:
  Trusted Advisor, Innovative, Excellence, Guardianship, Dedication and Caring.

Perform quality assurance and auditing processes for all lines of business to ensure accurate servicing operations, benefit information and functionality for adjudication within the pharmacy system, external communications, documentation as required by regulatory bodies and other operations and processes including but not limited to:

• Develop, implement, and maintain manual and automated test scripts utilizing testing tools.
• Develop, implement, and maintain test cases, data, files and strategies.
• Participate in all aspects of testing including functional, regression, performance and system testing.
• Log and manage defect status and resolution within the QA software tool.
• Develop, implement, and maintain policies, procedures, manuals, and other necessary documentation of the QA/QC process.
• Conduct internal audits to measure and ensure adherence to claims processing standards, technical requirements, supporting processes, systems, and required program documentation.
• Support cross-functional projects, represent the QA team at meetings, review requirements, develop test approach, and provide feedback.
• Work on issues of moderate to complex scope where analysis of data is required.
• Develop effective relationships that support appropriate feedback and development.
• Report QA and audit results to management and leadership teams.
• Identify, monitor and communicate trends in inaccuracies and work with PBD teams to resolve them, ensuring compliance with standards, policies, procedures, and government regulations.
• Perform ad hoc queries in audit database in support of decision making.
• Perform integration testing and track, document, and verify resolution while working with subject matter experts to resolve defects.
• Maintain knowledge of all line of business requirements and operational processes and develop plans to improve quality standards.
• Work with associates to predict, identify, resolve and document problems, clarify issues quickly and ensure successful resolution with minimal supervision.
• Develop and maintain interdepartmental relationships throughout the company.

Hiring compensation range: $24.00 - $27.00 hourly. Compensation may vary based on skills, education, location and experience. Associates may be…