Enrollment Quality Auditor

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $44k - $50k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates • Follow the customer quality process and tools for audit and rebuttal • Review enrollment (834) file transactions and coordinate with state enrollment systems and enrollment brokers • Confirm accuracy of member effective dates, retroactive enrollment/disenrollment, and eligibility segments • Verify timely and accurate processing of Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards • Audit dual-eligible Medicare-Medicaid enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits • Share QA results with associates and coordinate with operational Team Leads and managers to provide feedback • Collate, compile, and report team and individual QA performance to management and associates • Provide input to Training and Team Leads for processing instructions and refresher training needs • Participate in Audit the Auditor programs • Participate in semi-annual or annual auditor calibration activities • Maintain currency on CMS Medicaid managed care enrollment guidelines, applicable state Medicaid enrollment requirements, and MLTC enrollment/disenrollment rules • Report to the Lead Auditor or Quality Audit Manager and interact daily with client audit teams and operational managers

🎯 Requirements

• High School Diploma or GED required • 3 years health plan enrollment/eligibility auditing operations experience required • Medicaid managed care enrollment auditing experience preferred • Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience strongly preferred • Proficiency in MS Suite, specifically Excel, PowerPoint and Outlook • HealthRules® Payor or GuidingCare® experience preferred • Familiarity with EDI 834 enrollment transactions and eligibility verification systems a plus • Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness • Ability to effectively communicate and collaborate with a remote team • Ability to work independently with limited supervision and collaboratively in a team environment • Candidates may be required to complete a pre-employment criminal background check

🏖️ Benefits

• Remote work environment • May require travel dependent on company needs • Reasonable accommodations for individuals with disabilities • Equal opportunity employer committed to workforce diversity