QA Auditor, Appeals and Grievances

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.
This position is 100% remote

*This position is Remote

• 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 of investigations to senior staff and prepare written reports concerning investigation activities.
• Subsequent auditing and handling of specific appeal and grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
• Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.
• Assist in the development of departmental policies and procedures; reviews the efficiency of existing training.
• Meet established time frames and rates of performance for the quality and quantity of work for the position.
• Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities
• Additional duties as assigned

Minimum Qualifications: 

• Experience with the investigation, resolution, and reporting of appeal and grievance processes.
• Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations).
• High School Diploma or GED from an accredited institution

Preferred Qualifications: 

• Associate degree from an accredited institution.
• ICD10 certification
• Experience in an Auditing capacity conducting root cause analysis
• Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family
• Experience handling confidential information.
• Compliance & Regulatory Responsibilities: Knowledge of state and federal appeal and grievance regulatory requirements
• License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability 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 [email protected] 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

All hiring and recruitment at Healthfirst is transacted with a valid “@healthfirst.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @healthfirst.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $57,408 - $76,960

• All Other Locations (within approved locations): $49,795 - $72,800

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.