QA Ops Auditor

The Quality Assurance Operations Auditor is responsible for performing Internal Quality Assurance Audits of non-financial Operational processes for internal employees, assisting with interpreting Clinical Care Manager call handling, and outsourced vendors to ensure compliance with policies, procedures, and quality standards. The incumbent investigates, audits, conducts root cause analysis, handles processing of determinations, and tracks/trends findings under minimal supervision.

• Perform routine random/target audits of operational processes (e.g., call centers, enrollment/terminations, invoicing/dunning, member/provider notifications, workforce management, sales/retention, etc.) across multiple lines of business and products
• Confirm employee adherence to company, state and federal policies and procedures including compliance and regulatory guidelines   
• Prepare written audit reports on findings and communicates audit findings with appropriate leadership
• Identify quality, operational efficiency, and production goal defects to support the improvement of departmental performance
• Identify patterns, trends and variances related to audited performance and provide feedback to appropriate leaders
• Meet established time frames and rates of performance for both quality and quantity of work
• Conduct compliance audits to ensure member’s and/or provider accounts are accurately and timely handled according to contracted and regulatory guidelines
• Provide suggestions and recommendations on improving controls to gain efficiency and strengthening of performance and compliance measures
• Assist in the development of departmental policies and procedures
• Review the accuracy and efficiency of existing training materials
• Comply with HIPAA guidelines and maintain confidentiality of employee, member, provider, medical and departmental information
• Additional duties as assigned

Minimum Qualifications: 

• Healthcare operations experience working in a Quality Assurance, contact center, member enrollment and billing, or provider data management
• Prior working experience with Microsoft Office suite of applications including Excel (which includes formatting formulas, managing data, and filtering results), Word, PowerPoint, and Outlook
• Experience conducting analytical work and providing creative ideas for problem solving
• Work experience requiring written and verbal communication that is clear, concise, grammatically correct, and professional
• High School Diploma or GED from an accredited institution

Preferred Qualifications: 

• Experience handling Personal Health Information (PHI) in a professional manner
• Experience in an Auditing capacity where you have conducted root cause analysis
• Ability and willingness to handle increasing workload and responsibility
• Willingness and ability to learn and evaluate new information, both technical and procedural
• Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, or Child Health Plus, etc.
• Associate degree or higher

Compliance & Regulatory Responsibilities: See Above

License/Certification: N/A

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 careers@Healthfirst.org 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): $47,403 - $62,400

• All Other Locations (within approved locations): $41,101 - $60,320

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.