The Appeals Quality Auditor performs routine quality audits in Appeals for one of the following teams; par provider, non-par provider and/ or members using a prescriptive audit tool to verify the completeness, accuracy and adherence to departmental procedures and documentation guidelines of randomly selected appeal files. Documents and reports findings by individuals and teams. When indicated, gives one-on-one training in response to unfavorable audit scores.
Department: 3000 - HS - Appeals & Grievances
Manager title: Mgr. Quality & Audit
- Conducts routine quality reviews of staff level work.
- Tracks and maintains quality results for appropriate distribution.
- Communicates audit results in a structured report format.
- Coaches and gives feedback to individuals based on error findings.
- Facilitates individual training regarding the competencies needed based on audit results.
- Maintains audit tools consistent with regulatory guidelines.
- Creates new audit tools as warranted by business growth.
- Assists in identifying and communicating process improvement opportunities across Appeals based on quality audit reviews.
- Supports management staff with internal and external audit preparations
- Proofs regulatory reporting for data accuracy
- Serves as plan contact/touch point for Maximus and/or other external auditors as needed
- Assists with special projects and other duties as assigned
- A High School Diploma required. An Associate's Degree preferred.
- 3 years practical work experience in a Claims, Customer Service or healthcare environment.
- 1 years experience in appeals or grievances.
Special Skills (e.g. 2nd language):
- Desmonstrated technical expertise in performing quality reviews along with analyzing results
- Solid understanding of appeals, managed care and the healthcare industry
- Strong verbal and written communication skills
- Strong verbal communication skills to facilitate training for competency