Appeals and Grievances Quality Assurance Auditor

Job description

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 Healthfirst’s Culture Drivers through his/her workplace behavior and works under minimal supervision. - 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...