Note: The job is a remote job and is open to candidates in USA. Healthfirst is a healthcare organization, and they are seeking a Quality Assurance Auditor responsible for performing internal quality audits of operational processes. The role involves investigating, auditing, and ensuring compliance with policies and quality standards while working under minimal supervision.
Responsibilities
- Conduct quality audits of A&G items including grievances, pre-service appeals, and post service appeals utilizing appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete the request. Analyze errors and determine root causes for appropriate classification, trending, and remediation
- Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality
- Review and investigate appeals and grievances requests to ensure all requests are identified, classified, and fully resolved in a compliant manner
- Present results of investigations to senior staff and prepare written reports concerning investigation activities
- Subsequent auditing and handling of specific appeal and grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations
- Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals
- Assist in the development of departmental policies and procedures; reviews the efficiency of existing training
- Meet established time frames and rates of performance for the quality and quantity of work for the position
- Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities
- Additional duties as assigned
Skills
- Experience with the investigation, resolution, and reporting of appeal and grievance processes
- Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations)
- High School Diploma or GED from an accredited institution
- Associate degree from an accredited institution
- ICD10 certification
- Experience in an Auditing capacity conducting root cause analysis
- Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family
- Experience handling confidential information
- Compliance & Regulatory Responsibilities: Knowledge of state and federal appeal and grievance regulatory requirements
Benefits
- Medical
- Dental and vision coverage
- Incentive and recognition programs
- Life insurance
- 401k contributions
Company Overview
Healthfirst is a health insurer providing medical, business, and health insurance services. It was founded in 1993, and is headquartered in New York, New York, USA, with a workforce of 1001-5000 employees. Its website is https://healthfirst.org.Company H1B Sponsorship
Healthfirst has a track record of offering H1B sponsorships, with 35 in 2025, 26 in 2024, 19 in 2023, 31 in 2022, 3 in 2021, 11 in 2020. Please note that this does not guarantee sponsorship for this specific role.
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