Operations Quality Auditor - Member Appeals

Amerihealth Caritas Health Plan Philadelphia , PA 19107

Posted 2 months ago


The Member Appeals Auditor is responsible for completing independent, objective internal compliance audits designed to test and confirm compliance with applicable State and Federal guidelines, reporting to the Manager of Quality Auditing.

The auditor will also serve as a subject matter expert within the Company regarding standard monitoring and auditing procedures and best practices.

  • Performs reviews of Member Appeal episodes to ensure all contractual requirements have been met and all appeal components have been completed accurately.

  • Plans and executes independent, objective internal audits designed to test and confirm compliance with applicable State and Federal laws.

  • Analyzes and understands regulatory requirements, and applies identified requirements to business operations when developing and conducting compliance audits.

  • Coordinates and performs audit procedures; creates work products such as audit analysis; prepares audit plan and final report summary.

  • Monitors the progress, up to the remediation, of all deficiencies once identified.

  • Supports the fulfillment of internal/external audits as required.

  • Performs other job related duties and projects as assigned.


  • Minimum 3 years' auditing experience in a Medicaid environment.

  • High School/GED required.

  • Medicaid Appeals knowledge required, preferably with the Facets system.

  • Working knowledge of Microsoft Office applications.

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Operations Quality Auditor - Member Appeals

Amerihealth Caritas Health Plan