About this role
Role Overview: The Operations Quality Auditor is responsible for conducting timely, accurate quality reviews of operational functions, including claims processing.
Work Arrangement:
- Remote - This position is fully remote and may be performed from any location within the United States (US), with required availability during Eastern Standard Time (EST) hours.
- Associates must have access to a reliable high ‑ speed internet connection capable of supporting daily responsibilities, with a minimum bandwidth of 50 Mbps download and 5 Mbps upload. Fully remote associates residing in states where reimbursement is required by contract, law, or regulation may submit for appropriate expense reimbursement.
Responsibilities:
- Identify system and/or operational issues that impact the achievement of established quality performance standards.
- Analyze audit results to determine root causes of errors or trends affecting quality outcomes.
- Provide clear issue identification, problem analysis, and recommendations for resolution or process improvement to management.
- Accurately document audit findings, trends, and observations within designated quality tracking tools.
- Support quality improvement initiatives by sharing insights and contributing to corrective action strategies as needed.
Education & Experience:
- High School Diploma or GED required.
- 3 years of provider experience in a Medicaid managed care environment required.
- Claims processing knowledge, preferably using the Facets system required.
- Experience in call center operations and member/provider database maintenance preferred.
- Working knowledge of Microsoft Office applications required.
Skills & Abilities:
- Strong attention to detail with the ability to accurately review and assess operational work.
- Solid understanding of claims processing workflows and quality standards within a Medicaid environment.
- Ability to identify trends, analyze issues, and communicate findings clearly and effectively.
- Strong written documentation skills, with the ability to clearly record audit results and observations.