• QA Auditor, Appeals and Grievances

    Healthfirst (NY)


    + 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 provide feedback to reduce errors and improve processes and performance to ensure quality.

    + 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 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 universe review, universe 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 Microsoft Office suite of applications including Excel (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 capacity conducting root cause analysis

    + Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, 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

    + License/Certification: NA

     

    WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.