Senior Quality Verification Specialist

🔥 28 minutes ago

🇺🇸 United States – Remote

💵 $63k - $90k / year

⏰ Full Time

🟠 Senior

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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 independent, second-level quality and compliance reviews using an “audit-the-auditor” approach • Reassess completed verification reviews and retest evidence, controls, decisions, and handoffs • Evaluate member and provider interactions involving account access requests and provider EFT change requests • Apply random, risk-based, targeted, and retrospective review methodologies • Retest identity, representative authority, affiliation, ownership, authentication, call-control, disclosure, and documentation requirements • Evaluate request completeness, supporting evidence, signatures, organizational relationships, email and website validations, banking information, ownership, authorized exceptions, and portal access administration • Report review scope, sampling methods, findings, risks, severity, rationale, and recommendations • Present results to compliance leadership, business leaders, and process owners • Immediately escalate suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and significant compliance issues • Track remediation, support root-cause analysis, validate corrective actions, and escalate overdue or ineffective actions • Preserve complete, traceable review evidence in accordance with retention, access, and legal hold requirements • Translate trends and findings into recommendations for training, procedures, workflows, system enhancements, automation, and control improvements • Coach Verification Specialists, support onboarding and knowledge sharing, identify training needs, and recommend updates to procedures and reference materials • Support authorized operational verification and follow-up work while maintaining separation from reviews of the same cases • Maintain objectivity, avoid conflicts of interest, and route cases with direct involvement to an independent reviewer

🎯 Requirements

• Five or more years of experience in member services, member or provider verification, provider enrollment, healthcare operations, compliance operations, or a related field, including quality reviews or operational control testing across multi-step workflows • Ability to apply policies and procedures, independently reassess completed verification reviews, retest underlying controls and handoffs across the account access and provider EFT change-request lifecycle, reconcile conflicting information, and document objective, evidence-based conclusions • Working knowledge of member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and cross-team handoffs • Strong analytical, organizational, and time-management skills • Clear written and verbal communication; ability to prepare findings reports, present results and risk-based recommendations, guide and coach Verification Specialists, and partner on improvements • Proficiency with Microsoft Office and SharePoint • Ability to use case-management systems, approved records repositories, and interaction-recording or quality-review platforms • Preferred: Experience in Medicaid member services or provider operations, quality reviews related to account access and provider EFT change requests, or end-to-end reviews of EFT, portal administrator access, or other high-risk provider changes • Preferred: Experience with independent second-level quality reviews, risk-based sampling, finding classification, root-cause analysis, corrective-action validation, cross-functional trend reporting, and recommendations for improvements • Preferred: Familiarity with CXone or comparable interaction-review platforms, member and provider systems of record, and business-verification tools • Video cameras must be used during interviews and the initial week of orientation • Photo will be taken during screening for verification in all steps of the recruitment process

🏖️ Benefits

• Work flexibility • Learning and career development • Flexible vacation policy • 401(k) employer match • Comprehensive health benefits • Educational assistance • Leadership and technical development academies • Fully remote options from most US locations and territories

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