Quality Auditor - Enrollment (Health Plan)

About the role

Founded in 1977 as the Senior Care Action Network, SCAN has grown to serve over 500,000 people across multiple states with over $8 billion in annual revenue. Our mission is to improve care for older adults through innovative and compassionate practices.

Responsibilities

• Perform routine and targeted operational quality audits across health plan operations including Enrollment to ensure compliance with regulatory requirements, internal policies, contractual obligations, and operational standards.
• Maintain efficient and compliant operations by applying correct status attributes to track and trend issues.
• Notate cases/audits with required detail to ensure status understanding and final resolutions.
• Work closely with other business units to review and correct processing errors.
• Follow policies and procedures to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management.
• Identify and report problems with workflows following proper departmental procedures; actively participate in departmental staff meetings and training sessions.
• Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of health plan Enrollment.
• Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including quality, productivity, and attendance.
• Escalate appropriate audit issues to management as required and follow departmental/organizational policies and procedures.
• Maintain required levels of production and quality standards as established by management.
• Contribute to overall department success by participating in department initiatives, effective communication, and collaboration with all members of the SCAN team through knowledge and idea sharing.
• Take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers.
• Actively support the achievement of SCAN’s Vision and Goals.

Qualifications

• Associate’s degree preferred or equivalent experience
• 3+ years complex auditing processing and/or auditing experience in the health plan, healthcare, or managed care organization with experience in Enrollment
• Must be proficient in processing/auditing for Medicare and Medicaid plans
• 3+ years’ experience in managed healthcare environment related to Enrollment
• Strong organizational, analytical thinking and accounting skills; oral and written communication skills
• Strong knowledge of CMS requirements regarding auditing processing
• Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience
• Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment
• Strong PC Skills. Microsoft Office (Word, Excel, Outlook, Teams) are required