Quality Verification Specialist

🔥 0 minutes ago

🤠 Texas – Remote

🤠 Texas – Remote

💵 $50.4k - $72k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

🚫👨‍🎓 No degree required

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Gainwell Technologies

WebsiteLinkedInAll Job Openings

10,000+ employees

💼 Consulting

📦 Logistics

⚕️ Healthcare Insurance

💰 Grant on 2023-06

Consulting • Logistics • Healthcare Insurance

Gainwell Technologies is the nation’s leading provider of digital and cloud-enabled solutions across the human services and public health ecosystem. With a mission-driven approach, Gainwell serves clients in all 50 U. S. states, focusing on improving health outcomes and delivering intuitive, human-centered experiences. Their comprehensive suite of solutions includes Medicaid Enterprise modernization, data analytics, provider services, and pharmacy solutions, all designed to advance the future of healthcare and enhance community well-being.

📋 Description

• Conduct secondary reviews of completed verification work for member and provider account access requests and provider EFT change requests • Evaluate supporting evidence and approve, deny, or escalate requests within delegated authority • Assess identity, representative authority, and required controls under approved account procedures • Evaluate interactions, documentation, and verification results for completeness, consistency, and compliance • Confirm authentication and information-protection controls were followed and return incomplete or unsupported requests for correction • Record decision rationale and required next steps, obtaining separate operational, Privacy, compliance, or business-owner approvals when required • Identify discrepancies, suspected fraud, and privacy or security concerns • Pause affected work, preserve evidence, and follow escalation and communication protocols • Communicate outcomes, missing-information requirements, and next steps to submitting agents • Maintain secure, accurate, traceable case records, original evidence, and audit trails • Partner with compliance liaisons, account leaders, and process owners to identify recurring issues and implement improvements • Support root-cause analysis, corrective actions, procedural guidance, calibration, onboarding, training, and knowledge sharing • Recommend procedure and resource updates and refer policy questions and exceptions to designated compliance authorities

🎯 Requirements

• High school diploma or equivalent • Two or more years of experience in member or provider services, provider enrollment, healthcare operations, verification, quality assurance, compliance operations, or a related field • Experience reviewing documentation, resolving discrepancies, or applying approval and escalation criteria • Ability to apply procedures, evaluate completed verification work, identify gaps, and make evidence-based approval, denial, or escalation decisions within delegated authority • Working knowledge of confidential-information protection, fraud indicators, and escalation practices • Ability to learn and apply account-specific identity and representative verification requirements, account access safeguards, and provider EFT controls • Strong attention to detail, judgment, organization, and time management • Clear written and verbal communication and ability to collaborate across compliance, quality, and account teams • Proficiency with Microsoft Office and SharePoint, case-management, records, and interaction platforms • Preferred: Three or more years of relevant experience • Preferred experience reviewing identity, representative authority, provider applications, or financial supporting documentation • Preferred familiarity with member and provider systems, verification tools, and secure case documentation • Preferred experience with quality findings, corrective actions, root-cause analysis, training, or cross-account process improvements • Ability to join screenings, interviews, and meetings from a quiet location with stable internet • Video camera required during interviews and initial orientation week

🏖️ Benefits

• Work flexibility • Learning and career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies