Quality Auditor

Meridian Detroit , MI 48222

Posted 11 months ago

Overview

Who we are:

Meridian, a WellCare Company, is part of a national network of passionate leaders, achievers, and innovators dedicated to making a difference in the lives of our members, our providers and in the healthcare industry.

We provide government-based health plans (Medicare, Medicaid, and the Health Insurance Marketplace) in Michigan, Illinois, Indiana, and Ohio. As a part of the WellCare Family of companies, we deliver healthcare excellence to millions of members nationwide.

Our associates work hard, play hard, and give back. Meridian associates enjoy an exceptional experience and culture including special events, company sports teams, potlucks, Bagel Fridays, and volunteer opportunities.

A Day in the Life of a Quality Auditor:

This position is responsible for the coordination of audits and reports for Appeals. This includes responsibility for preparation, quality review and reporting for all audits, both internal and external. This position is also responsible for ensuring any reporting requirements for Appeals are met. Annual policy review is also completed by this person for Appeals

Responsibilities

  • Coordinate audit compilation to carry forth quality audit files in the timeline required. This is to include drafting of audit tools, completion of audit reports, quality review of audit files prior to submission for audit

  • Communicate status and results of audits to department leadership to include suggestions for changes needed for audit deficiencies

  • Understand accreditation, contract, State and Federal requirements as they relate to Appeals

  • Perform individual, departmental and specialized audits within the department.

  • Assess accuracy and consistency of an individual Appeal coordinator

  • Identify training needs to improve quality and efficiency

  • Coordinate both internal and external daily, monthly, quarterly and annual reports

  • Develop and maintain mechanisms to track and organize reporting requirements

  • With Collaboration with the department analyst, perform ongoing analysis of appeal trends

  • Conduct annual review of existing policies relating to Appeals

  • Make suggestions to management for any identified lines of business Appeals to include identification in any deficiency in current process, policy or systems application that would have the potential to delay or hinder a successful implementation

  • Assist department in drafting policies to address process or deficiency, as identified

  • Assist department leadership in monitoring and tracking any CAP (Corrective Action Plan) items assigned to the Appeals and Grievance department

  • Perform other duties as assigned

Qualifications

What you can bring to Meridian:

  • High School Diploma or GED required

  • Bachelor's Degree with emphasis in Business or Healthcare or Fellow designation from the Academy for Healthcare Management (AHM) preferred

  • Current licensure to practice as a Registered Nurse or a Licensed Practical preferred

  • Minimum 3 years of related experience in a healthcare field required

  • Minimum 2 years of experience working with regulatory requirements

  • Experience in a managed care environment is desired

  • Knowledge of MHP's mission and operational structure

  • Advanced knowledge of Grievance and Appeals policies and procedures

  • Knowledge of managed care, particularly grievance and appeals processes is desired

  • Knowledge of Medicaid and Medicare guidelines, medical necessity and benefit structure

  • Knowledge of NCQA, URAC or general accreditation requirements and guidelines for member satisfaction, grievances, utilization management, denials and appeals

What Meridian can offer you:

  • Our healthcare benefits include a variety of plans that are effective on the first day of employment for our new full-time team members.

  • Opportunity to work with the industry's leading technologies and participate in unique projects, demonstrations, conferences, and exclusive learning opportunities.

  • Meridian offers 401k matching that is above the national average.

  • Full-time Meridian employees are eligible for tuition reimbursement towards Bachelor's or Master's degrees.

  • Meridian was named Detroit's #1 Fastest Growing Company by Crain's Magazine, so it is a great time to get involved with Meridian.

Equal Opportunity Employer

#MSTR


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Quality Auditor

Meridian