UST HealthProof · 14 hours ago
Appeals & Grievances QA
United States
Full-time
Remote
Mid Level
$42K/yr - $50K/yr
3+ years exp
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Responsibilities
Completes quality audits across all functions of Back Office Operations, reviewing completed work in comparison to established documented procedures to determine accuracy.
Complies and reports all audit activity and results weekly to leadership team
Providers monthly assessment and analysis of audit results
Identify training opportunities based on quality assessment results
Conducts reviews of DLPs across functional areas for accuracy of information and instruction.
Collaborates with each Operations manager to build and execute specific functional audit plans for Claims, Configuration, Appeals and Grievances and Billing and Enrollment functions.
Perform audit related investigation to troubleshoot error trends as it relates to business processes and/or training.
Coordinates the impact of regulatory changes and updates to policies, practices and procedures and works closely with managers and stakeholders to appropriately translate the updates to the end user.
Reviews, evaluates and makes recommendations for process improvements.
Assists in the creation of departmental procedures and reference documents.
Participates in projects as assigned.
May be responsible for researching operational audit best practices and making recommendations for improvement.
Maintains confidentiality of all information processed.
Qualification
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Required
Bachelor’s degree or equivalent experience. Background in insurance, business or a related field.
3 to 5 years of relevant work experience can be experience working in corporate environment, preferably in health care environment and/or internal audit experience.
Working knowledge of CMS guidance and business area development procedures, workflows, and rules for multiple states.
Excellent analytical skills to identify opportunities for improvement and recommend solutions.
Strong analytical and problem-solving skills.
Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information, and respond to questions as appropriate.
Ability to read, analyze and interpret policy documents, technical, legal and financial information, and procedures manuals.
Excellent verbal and written communication skills.
Ability to manage multiple projects and meet necessary deadlines.
Basic knowledge of computers, spreadsheet software, and word processing and ability to enter accurately 50 WPM.
Ability to perform mathematical calculations.
Ability to proofread documents for accuracy of spelling, grammar, punctuation and format and edit as necessary.
Ability to maintain confidentiality.
Ability to create surveys and survey criteria.
Completion of industry recognized quality or internal audit certification(s).
Advanced knowledge of industry best practices related to sound internal controls and audit techniques.
Ability to assist in the development and implementation of policies, practices, and procedures.
Preferred
Experience working in government program (Medicare and Medicaid) preferred or three (3) or more years experience in an insurance organization which provides working knowledge in one or more of the following areas: claims management, underwriting, finance or auditing; insurance education coursework.
Certification or progress toward certification in courses focused on but not limited to Quality Auditor, Quality Manager, Six Sigma or other quality designations is highly preferred and encouraged
Benefits
Full-time, regular employees accrue up to 16 days of paid vacation per year
Receive 6 days of paid sick leave each year (pro-rated for new hires throughout the year)
10 paid holidays
Eligible for paid bereavement leave
Participate in the Company’s 401(k) Retirement Plan with employer matching
Eligible for medical, dental, and vision insurance
Basic life insurance
Accidental death and disability insurance
Short- and long-term disability benefits
Purchase additional voluntary short-term disability benefits
Participate in a Health Savings Account (HSA)
Flexible Spending Account (FSA) for healthcare, dependent child care, and/or commuting expenses
Potential for quarterly incentive-based bonuses and or commissions depending on role
Company
UST HealthProof
We are a trusted partner for health plans, offering an integrated ecosystem for health plan operations.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Kevin Adams
Chief Executive Officer
Beth Maxwell
VP Product Delivery and Partnerships
Company data provided by crunchbase
