Quality Auditor/Analyst, Grievance and Appeal

Company

Navitus

Work Schedule Description (e.g. M-F 8am to 5pm)

M-F 8am to 5pm

Remote Work Notification

ATTENTION: Navitus is only able to offer remote work to residents of Alabama, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, Nevada, New Jersey, New York, North Carolina, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Washington DC, Wisconsin.

Hiring Manager : Full Name: First Last

Derek Sheffer

Overview

Due to growth, we are adding a Quality Auditor and Analyst, Grievance and Appeals to our team.

 

The Quality Auditor and Analyst, Grievance and Appeals (G&A) is responsible for evaluating and improving case accuracy of our G&A Coordinators. This will include but is not limited to performing quality and consistency audits on all roles for employees in the G&A department, establishing and/or maintaining grievance and appeals audit policies and procedures based on expert level knowledge of compliance and regulatory requirements for Medicaid, Medicare, Commercial and Marketplace. In coordination with the G&A department leaders, the Quality Auditor and Analyst will assist and/or lead all department audits including those conducted by the Centers of Medicare and Medicaid Services (CMS), clients, and state regulatory bodies. The Quality Auditor and Analyst will use established audit tools to perform and report on audits to include quantitative and qualitative analyses. The Quality Auditor and Analyst will coordinate the training and re-training of G&A Coordinators in cooperation with the G&A department leaders. The Quality Auditor and Analyst will continually monitor the overall quality of the G&A work and build training to address areas identified as gaps in knowledge. The Quality Auditor and Analyst will assist department leaders by preparing responses to audit questions or findings, working closely with internal departments who need this information, including the Navitus Government Programs and Compliance Departments. This position will track and be knowledgeable with reporting Quality metrics and provide this information to department leaders. This position will also contribute to running monthly and quarterly reports for appropriate filing and timely submission of required monthly/quarterly reporting.

 

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team? 

• Responsible for Navitus Grievance and Appeals (G&A) quality and consistency audits
• Develops and provides ongoing training and education for G&A team
• Prepare and maintain necessary audit policies and procedures
• Assist the Grievance and Appeals coordinators with entry, when required
• Develop, adhere to, and coordinate audit work plan and submission of monthly and quarterly reports to ensure these occur and are delivered timely
• Data mine and assess large amounts of data, and compile into detailed reports to include quantitative and qualitative analyses
• Provide feedback, mentoring and coordination for training, and onboarding new staff as it relates to the G&A job functions
• Research best practices and assess program guidelines to maintain quality offerings for clients and members
• Responsible for maintaining compliance and awareness of current accreditations (URAC, NCQA, and other regulatory bodies)
• Other duties as assigned

Qualifications

What our team expects from you?

• Associate or bachelor’s degree strongly preferred
• 3-5 years of audit, analytical, compliance, reporting, managed care and/or insurance background preferred
• Strong knowledge of CMS coverage determination and redetermination processes preferred
• Experience with CMS, NCQA, URAC, and/or HHSC audits desired
• Emphasis on problem-solving skills, including identifying and accepting a challenging situation and creating and implementing a solution
• Proficiency in MS Word, Excel, Power Point including tables, charts and figures desired
• Advanced skills in appropriate software programs databases and QlikView to organize and trend data as well as to produce documents, charts, spreadsheets, etc
• Participate in, adhere to, and support compliance program objectives
• The ability to consistently interact cooperatively and respectfully with other employees

What can you expect from Navitus?

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750!

#LI-Remote

Pay Range

USD $54,236.17 - USD $64,566.87 /Yr.