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 compliance audits to ensure members' accounts are accurately handled with the plan level selected. This includes the appropriate handling of effectuations, member record updates, terminations, binder and ongoing premium payments being posted timely and accurately.
Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network.
Provide suggestions and recommendations on improving controls to gain efficiency and strengthening of compliance measures.
Present results of investigations to senior staff and prepare written reports concerning investigation activities.
Use data analysis to make recommendations to improve processes.
Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
Assist in the development of departmental policies and procedures; review the efficiency of existing training.
Meet established time frames and rates of performance for the quality and quantity of work for the position.
Additional duties as assigned.
Leads development projects for new audits and provide maintenance on established audit processes.
Experience demonstrating analytical thinking, problem-solving, and critical thinking skills.
Experience with auditing billing and accounting.
Experience with MS Excel with concentration on advanced formulas (i.e. v-lookups), Macros, and pivot tables, SharePoint.
Experience creating presentations in Microsoft PowerPoint and conducting presentations.
High School Diploma or GED from an accredited institution.
Associate degree from an accredited institution.
Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Qualified Health Plan, Essential Plan, Child Health Plus, NH Family.
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, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.
If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@Healthfirst.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.
EEO Law Poster and Supplement