Senior Quality Verification Specialist

Great companies need great teams to propel their operations. Protect member and provider information through independent, second-level quality reviews using an “audit-the-auditor” approach. Your scope includes assessing member and provider interactions related to member and provider account access requests, including portal administrator access changes, and provider Electronic Funds Transfer (EFT) change requests. You’ll report findings, communicate results, and partner with account leaders to drive people, process, and technology improvements, validate corrective actions, and guide Verification Specialists while maintaining review independence.

You will be responsible for conducting independent quality and compliance reviews of member and provider interactions involving account access requests and provider EFT change requests. Working closely with Compliance, Operations, Quality, Privacy, Security, and other authorized stakeholders, the reviewer evaluates end-to-end request processing, documents findings, validates corrective actions, and confirms sustained process improvements. The position serves as an objective quality resource, providing clear reporting, risk identification, and compliance guidance while maintaining independence from operational decision-making.

Serve as an independent line of defense by evaluating verification activities, identifying risks, and ensuring compliance with established policies, procedures, and controls. Your work helps protect member and provider information, strengthen operational integrity, and support regulatory compliance.

Independently reassess completed reviews using an "audit-the-auditor" approach to evaluate the completeness, accuracy, consistency, and appropriateness of prior verification reviews, findings, decisions, and escalations. Apply random, risk-based, targeted, and retrospective review methodologies while retesting controls, documentation, decisions, and handoffs against requirements in effect at the time of processing.

Assess member and provider interactions related to account access requests and provider EFT changes, ensuring information accuracy, professional communication, proper authorized representative handling, complete documentation, and compliance with escalation and follow-up requirements.

Test high-risk request controls by evaluating request completeness, supporting evidence, signatures, organizational relationships, email and website validations, banking information verification, ownership verification, authorized exceptions, and portal access administration activities.

Document review scope, sampling methods, findings, risks, severity, rationale, and recommendations, while presenting results to compliance leadership, business leaders, and process owners.

Escalate critical risks immediately, including suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and other significant compliance issues in accordance with established escalation procedures.

Validate corrective actions by tracking remediation efforts, supporting root-cause analysis, confirming effectiveness of corrective measures, and escalating overdue or ineffective actions.

Leverage audit and quality findings to improve processes, strengthen controls, and support organizational performance through collaboration, coaching, and continuous improvement initiatives.

Preserve review evidence by maintaining complete, traceable records tied to original case documentation while adhering to retention, access, and legal hold requirements.

Drive people, process, and technology improvements by translating trends and findings into actionable recommendations for training, procedures, workflows, system enhancements, automation opportunities,…