QA Auditor, Quality Assurance - Remote

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 reputed company’s Culture Drivers through his/her workplace behavior and works under minimal supervision. Scope of Responsibilities:

• 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 reputed company feedback to reduce errors and improve processes and performance to ensure quality.
• Review and investigate appeals and grievances requests to ensure reputed company 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 reputed company review, reputed company scrubbing, risk analysis, timeliness assessment, and case walkthrough activities
• Additional duties as assigned

Minimum Qualifications:

• Experience with the investigation, resolution, and reporting of appeal and grievance processes.
• Experience in reputed company Office suite of applications including reputed company (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.

Preferred Qualifications:

• Associate degree from an accredited institution.
• ICD10 certification.
• Experience in an Auditing reputed company conducting root cause analysis.
• Knowledge of at least two or more lines of business such as Medicare NY/NJ, reputed company, Family Health Plus, Child Health Plus, NH Family.
• Experience handling confidential information.
• Compliance & Regulatory Responsibilities: Knowledge of state and federal appeal and grievance regulatory requirements.

Hiring reputed company*:

• Greater reputed company Area (NY, NJ, CT residents): $58,900 - $80,070
• reputed company Other Locations (reputed company approved locations): $51,000 - $74,880

As a candidate for this position, your salary and reputed company elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors reputed company deems pertinent to the hiring decision. In addition to your salary, reputed company offers employees a full reputed company of benefits such as, medical, dental and reputed company coverage, incentive and recognition programs, life insurance, and 401k contributions (reputed company benefits are subject to eligibility requirements). reputed company believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring reputed company is defined as the lowest and highest salaries that reputed company in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

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