QA Auditor - Appeals & Grievances - Remote

Med-Metrix

Garden City, NY(remote)

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JOB DETAILS

SALARY

$75,000–$80,000 Per Year

JOB TYPE

Full-time

SKILLS

Analysis Skills, Auditing, Business Development, Case Management, Claims Management, Claims Processing, Communication Skills, Corrective Action, Customer Support/Service, Data Analysis, Debugging Skills, Denials Management, Detail Oriented, Documentation, Establish Priorities, Genetics, HIPAA (Health Insurance Portability and Accountability Act), Health Insurance, Information/Data Security (InfoSec), Interpersonal Skills, Maintain Compliance, Managed Care, Medical Records, Medical Writing, Microsoft Excel, Microsoft Word, Military, Office Equipment, Operational Support, Patient Care Denials, People Management, Performance Management, Peripheral Hardware, Presentation/Verbal Skills, Problem Solving Skills, Process Development, Process Improvement, Quality Assurance, Quality Management, Quality Metrics, Registered Nurse (RN), Regulatory Requirements, Reporting Skills, Security Compliance, State Laws and Regulations, Strategic Planning, Team Player, Time Management, Willing to Travel, Writing Skills

LOCATION

Garden City, NY

POSTED

1 day ago

Job PurposeThe QA Auditor performs audit functions across Client Teams to determine operational efficiency, adherence to internal processes and procedures as well as regulatory requirements, and achievement of quality standards. This role requires an in-depth understanding of the denials management process, a clinical background, attention to detail, and the ability to effectively assess the quality of work completed. The QA Auditor will work closely with internal teams to provide feedback, maintain high standards of quality, and ensure compliance with established processes.Duties & Responsibilities Conduct regular audits of work performed by appeal writers and automated processes to ensure adherence to internal policies and quality standards in the denials management processEvaluate how denials are handled, ensuring that all necessary steps are followed, documentation is accurate, and appropriate actions are taken. Identify defects and improve departmental performance by supporting quality, operational efficiency and production goalsOffer constructive feedback to appeal writers based on audit results, identifying areas for improvement and providing guidance on corrective actions. Provide feedback on automated processes to ensure the highest levels of efficiency in overturning denialsMaintain accurate records of audit findings and track trends or recurring issues in the denials management process. Prepare reports to share with management and relevant teams. Develop strategies for business performance improvement initiatives, including includes: identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reportsUtilize and navigate multiple internal systems (e.g., claims processing systems, communication tools) to review audit data and provide feedback. Adapt to new systems as necessaryWork closely with appeal writers, managers, and other stakeholders to foster a collaborative approach to quality improvement and process optimizationAdditional duties as assignedUse, protect and disclose patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standardsUnderstand and comply with Information Security and HIPAA policies and procedures at all timesLimit viewing of PHI to the absolute minimum as necessary to perform assigned dutiesQualificationsState Licensed RN is requiredExperience working in a healthcare or insurance environment, particularly with claims and denials managementFamiliarity with common claims management and denial resolution systemsExperience in quality auditing or process improvement initiativesFamiliarity with MCG and Interqual guidelines and processesStrong understanding of the denials management process, including common causes of denials and strategies for resolution.Prior experience with medical records review, claims processing, utilization/case management in a clinical practice or managed care organization, Clinical Appeal Writer, etc.Advanced knowledge of Microsoft Word, Excel, and Teams for communication, data analysis, and reportingAbility to quickly learn and effectively navigate multiple software systems, providing accurate and timely feedbackStrong analytical skills with the ability to detect issues, inconsistencies, and areas for improvement in the denials management processAbility to manage multiple audits simultaneously while maintaining accuracy and efficiencyStrong interpersonal skills, ability to communicate well at all levels of the organizationStrong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analysesHigh level of integrity and dependability with a strong sense of urgency and results oriented Excellent written and verbal communication skills requiredGracious and welcoming personality for customer service interactionWorking ConditionsAbility to travel to client sites on occasionAbility to work outside of normal business hours as neededPhysical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.Work Environment: The noise level in the work environment is usually minimal.Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.

About the Company

Med-Metrix

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