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Position Summary:

The Quality Auditing Team Lead oversees daily operations of the Quality Auditing department with a strong emphasis on **provider audit** accuracy, provider contract adherence, and compliance with clinical, operational, and regulatory requirements. This role leads multiple audit types—including Provider Performance, Compliance, and Operational reviews—to ensure provider-facing processes meet AmeriHealth Caritas quality and documentation standards. The position also supports cross‑functional initiatives and special analytical projects aimed at improving provider experience, outcomes, and data integrity.

Key Responsibilities

+ Lead and manage provider‑focused audits, including Provider Performance audits, Compliance audits, Enterprise Operations reviews, Pre‑Production audits, and targeted provider audits.

+ Apply extensive knowledge of provider billing rules, reimbursement methodologies, documentation requirements, policies, and contract provisions across multiple lines of business; communicate trends and findings clearly.

+ Oversee the Quality Auditing appeals process related to provider issues, including documentation, tracking, decision-making, and resolution guidance.

+ Develop, refine, and implement audit protocols, provider audit procedures, and operational strategies to strengthen provider oversight and accuracy.

+ Identify trends, system issues, or operational gaps impacting provider data quality, claims accuracy, or audit outcomes; provide analysis and actionable recommendations to leadership.

+ Coordinate provider audit inventory, task assignments, and special projects to support timely and accurate audit completion.

+ Coach team members to enhance provider audit accuracy, documentation quality, and professional development.

+ Represent the Quality Auditing department in meetings with internal stakeholders, Provider Network teams, and cross‑functional initiatives impacting provider performance and quality.

+ Professionally respond to inquiries regarding provider audits, provider billing or documentation findings, appeals, and special project reviews.

+ Maintain comprehensive and compliant provider audit documentation per retention and regulatory standards.

+ Report issues related to provider audit tools, platforms, or supporting systems (e.g., Online Help, Facets, IAD).

Education & Experience

+ Bachelor’s Degree or equivalent professional experience.

+ Minimum 1 year of internal quality or provider auditing experience.

+ Minimum 3 years of healthcare industry experience, preferably in provider operations, provider relations, or claims.

+ Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint); Access preferred.

Skills & Abilities

+ Strong analytical and problem‑solving skills, with emphasis on provider documentation review, billing accuracy, trend identification, and policy alignment.

+ Excellent communication, leadership, and collaboration skills, especially when working across provider‑facing teams.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

**Why Join Us:** Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you are driven to make a difference, we want to hear from you.

About AmeriHealth Caritas

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at http://www.amerihealthcaritas.com

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.