QA Auditor,Appeals and Grievances Job Philadelphia area,Pennsylvania USA,Healthcare

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The Quality Assurance Auditor is responsible for performing Internal Quality Assurance Audits of operational processes for internal employees and outsourced vendors to ensure compliance with policies, procedures, and quality standards. The incumbent will investigate, audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The individual at this level will embody Healthfirst’s Culture Drivers through workplace behavior and works under minimal supervision.

Responsibilities include:

Conduct quality audits of A&G items including grievances, pre-service appeals, and post-service appeals utilizing appropriate sources of information; analyze errors and determine root causes for classification, trending, and remediation.

Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance.

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.

Handle follow-up audits and processing of specific appeal and grievance requests, including tracking, documenting, and reporting findings and recommendations.

Identify defects and support departmental performance improvements.

Assist in developing departmental policies and reviewing training efficiency.

Meet performance time frames and quality standards.

Participate in regulatory and mock audits, including universe review, risk analysis, and case walkthroughs.

Perform additional duties as assigned.

Minimum Qualifications:

Experience with investigation, resolution, and reporting of appeal and grievance processes.
Proficiency in Microsoft Office applications, including Excel, Word, and PowerPoint.
High School Diploma or GED from an accredited institution.

Preferred Qualifications:

Associate degree from an accredited institution.
ICD
10 certification.
Experience in auditing and root cause analysis.
Knowledge of multiple lines of business such as Medicare NY/NJ, Medicaid, etc.
Experience handling confidential information.
Knowledge of regulatory requirements for appeals and grievances.

Additional Details:

Salary ranges vary by location, with specific figures provided for the Greater New York City Area and other locations. Benefits include medical, dental, vision, life insurance, 401k, and more. The role is full-time, with employment in the healthcare industry.

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