QA Auditor II - Remote

QA Auditor II - Remote role at Healthfirst

The Quality Assurance Financial Auditor II is responsible for performing Quality Assurance Audits of financial processes completed by internal employees and outsourced vendors to ensure compliance with policies, procedures, and quality standards to mitigate financial risk. You will investigate, audit, conduct root cause analysis, handle processing of determinations, and track/trend findings under minimal supervision.

This position is 100% Remote.

• Conduct moderately complex to complex quality audits of provider claims, pre-payments and post-payments including high-dollar and specialized claims across multiple lines of business, claim types and products.
• Audit the work of more junior auditors and identify opportunities for coaching and/or training.
• Identify and communicate issues identified through audits and recommended solutions relevant to business operations.
• Assist management in preparing departmental reports policies and procedures.
• Mentor and coach Financial and/or Operations QA auditors.
• Participate as a Subject Matter Expert on various process improvement projects designed to meet departmental and operational needs.
• Assist with performing User Acceptance Testing (UAT) on system enhancements or corporate projects in partnership with Business Operations.
• Analyze errors and determine root causes for appropriate classification.
• Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network.
• Review and investigate claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst policy and procedure.
• Prepare written reports concerning investigation activities and present results of investigations to senior staff.
• Complete subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
• Review the accuracy and efficiency of existing training materials.

• Audit experience with the investigation, determination and reporting of financial processes.
• Work experience in Microsoft Office suite of applications including advanced Excel (formatting formulas, managing data, filtering results), Word, PowerPoint.
• Experience conducting root cause analysis in an auditing capacity.
• Experience conducting analytical work and providing creative ideas for problem solving.
• Work experience requires written and verbal communication that is clear, concise, grammatically correct, and professional.
• Experience handling confidential information.
• Associate degree from an accredited institution.

• Bachelor’s degree from an accredited institution.
• Audit experience with the investigation, determination and reporting of financial processes specifically around Healthcare Claims Adjudication and Claims Processing.
• Ability and willingness to handle increasing workload and responsibility.
  
  Willingness and ability to learn and evaluate new information, both technical and procedural.
• ICD
  10 certification.
• Basic foundation of SQL, Tableau, and SharePoint.
• Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, Child Health Plus.

Greater New York City Area (NY, NJ, CT residents): $58,900 - $80,070

All Other Locations (within approved locations): $51,000 - $74,880

Your salary and related compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements).

Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• Seniority Level: Not Applicable
• Employment Type:
  
  Full-time
• Job Function:
  Quality Assurance
• Industries:
  Hospitals and Health Care

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