*Applicants for this job have flexibility to work from home anywhere in the United States. This job is eligible for a $3,000 sign-on bonus.* Position Purpose
Performs complex and routine quality audits in Appeals for one of the following teams; par provider, non-par provider and/ or members using databases and a prescriptive audit tool to verify the completeness, accuracy and adherence to regulations, departmental procedures and documentation guidelines of randomly selected appeal files. Documents and reports findings by individuals and teams. Provides feedback and recommends improvements within the department. When indicated, gives one-on-one training in response to unfavorable audit scores. . Essential Functions
- Assists Quality Auditors with questions, casework, and complex cases.
- Conducts complex and routine quality reviews of staff level work.
- Tracks and maintains quality results for appropriate distribution.
- Communicates audit results in a structured report format.
- Coaches and gives feedback to quality auditors and coordinators based on error findings.
- Facilitates individual training regarding the competencies needed based on audit results.
- Maintains audit tools consistent with regulatory guidelines.
- Creates new audit tools as warranted by business growth.
- Assists in identifying and communicating process improvement opportunities across Appeals based on quality audit reviews.
- Supports management staff with internal and external audit preparations.
- Proofs regulatory reporting for data accuracy.
- Serves as plan contact/touch point for Maximus and/or other external auditors as needed.
- Assists with special projects and other duties as assigned.
- Assists in auditing activities for NCQA, URAC and other accreditation assessments.
- Represents Appeals department at meetings where metrics are presented.
- Performs other duties as assigned.
- Required A High School or GED
- Preferred An Associate's Degree in a related field
- Required 5+ years of experience in a Claims, Customer Service or healthcare environment
- Required 3+ years of experience in appeals or grievances
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.