Quality Auditor - Benefit Administration

We're excited about the potential people bring to our organization. You can grow your career here while enjoying first-class perks, benefits and a culture that fosters growth, innovation and collaboration.

The Quality Auditor-Benefit Administration will perform auditing and quality assurance procedures on the processes associated with Benefit Administration (BA), Healthcare Services (HCS), and associated delegated vendors. The Quality Auditor-Benefit Administration will be responsible for the collection and preparation of monthly random and targeted quality assessment reviews of work performed by various roles within HCS and Benefit Administration. The Quality Auditor-Benefit Administration will be responsible for performing quality assurance procedures and audits at a statistically significant volume through seasonal volume fluctuations, recording and reporting results and trending and escalating any pertinent issues to front line supervisors and/or managers. The Auditor will be accountable for collaborating with the Compliance team as well as the leadership team to reduce regulatory risk, ensure audit readiness, and implement corrective action plans, as applicable. The Quality Auditor will audit against all regulatory and quality elements as defined by the laws, regulations, and guidance. The auditor will support feedback and training, trend analysis, process improvement and regulatory compliance. The Quality Auditor-Benefit Administration will also provide support to the HCS and BA leadership team to help ensure the achievement and maintenance of accreditation and compliance with legal and appropriate regulatory mandates for health care. The auditor is responsible for supporting HCS and BA team to identify and support process improvement initiatives through performance data analysis. Overtime, weekend, and holiday work may be required to meet service standards.

• High School diploma or GED required. Associates degree preferred.
• Three (3) years of experience in auditing, quality assurance, customer service or training in the healthcare industry, to include outcome improvement required.
• Must be able to understand various regulatory requirements for all of Independent Health's product lines including knowledge of Medicare, Medicaid, Commercial, and other government programs required.
• Demonstrated quality and compliance accuracy scores.
• Experience with statistics and metrics reporting required.
• Demonstrated ability to work accurately at a demanding pace in order to meet or exceed minimum production goals.
• Highly detail oriented, while simultaneously maintaining awareness of overall production and accuracy goals.
• Demonstrated ability to understand and articulate complex systems, process and/or concepts and influence outcomes through clear and effective communication and collaboration.
• Ability to quickly learn and adjust to new tasks and adhere to established standards.
• Demonstrated proficiency in various computer applications including but not limited to proprietary systems, internet and intranets and Microsoft Office (Word, Excel).
• Demonstrated ability to work independently under strict deadlines, delivers on deadlines, and demonstrates flexibility to change direction when required, maintain confidentiality and make decisions commensurate with position responsibilities.
• Demonstrated ability to work collaboratively with others at all levels of an organization with effective communication skills to achieve common goals.
• Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

• Conduct random and targeted quality and regulatory audit assessments for all non-clinical elements of Benefit Administration (BA), Healthcare Services (HCS) and associated delegated vendors related to:
  • Verify correctness and accuracy of the work done by Benefit Administration (BA), Healthcare Services (HCS), and associated delegated vendors by analyzing multiple elements of each case reviewed to ensure regulatory and process compliance.
  • Identify whether the correct process was followed, and correct resolution was given.
  • Assess the quality of the documentation provided by Benefit Administration (BA), Healthcare Services (HCS), and associated delegated vendors.
  • Ensure all regulatory requirements are met.
• On a monthly basis, the auditor will receive a Medicare universe consisting of all ODAG and CDAG data as applicable to the supported departments to review for universe preparation and accuracy to ensure audit readiness.

• Influence customer centric performance outcomes through clear and effective communication and collaboration with the Compliance Team, BA Leadership, HCS Leadership, the associated delegated vendor representatives. Quality assessment reviews of all aspects of the department and vendor related to:
  • Verify correctness and accuracy of the work done by the department or vendor.
  • Identify whether the correct process was followed.
  • Assess the quality of the documentation provided by the department or vendor.
  • Ensure all regulatory requirements are met.
  • Develop effective relationships that support appropriate feedback and development efforts.
  • Support establishment of departmental "quality benchmarks" and report on success of corresponding quality improvement efforts.
  • Assist as requested in providing re-training suggestions for the associates.
  • Assist the management team in the design and development of training, structure and tools including standard operating procedures, training handbook and other materials.

• Receive, track and report on data for department performance. Compliance reporting includes but is not limited to:
• Quarterly Medicaid Action Appeal and Complaint Summary Report.
• Annual Schedule M for NYS.
• Annual External Appeal Review for NYS.
• Annual HPMS Report.
• Monthly turnaround time reports.

• Monitor the production of quality results reporting; analyze, track and trend the reporting results and report them to management.
• Facilitate and assist with HCS, BA, and vendor universe preparation for NCQA, NYSDOH onsite review, CMS and other external regulatory bodies as needed. This includes gathering of performance metric monitoring documentation, case preparation and review, meeting minutes for oversight teams. This does include reviewing Utilization Management and Benefit Administration data/QA of information prepared.
• Keep abreast of industry standards and outside entity requirements (i.e. NCQA, DOH, and CMS etc.) and works closely with vendor processes and programs are compliant with all applicable standards.
• Prepare and deliver daily, weekly, and monthly reporting statistics to HCS leadership team and any related corporate or cross-functional teams related to associate performance, departmental goals, and vendor performance.
• Develop, update, and maintain quality audit dashboards for HCS leadership. Report on measures as needed by leadership.
• Perform administrative support functions as needed. This includes assisting the team in Benefit Administration with appeal and letter review.

• Systematically review standard operating procedures (SOP), policies, inter-departmental relationships and systems support/integrations against best practice standards, efficiency, customer outcome improvement and regulatory/auditing standards and collaboratively recommend changes.
• Remain informed and up to date on current and upcoming changes in State, Federal, Quality and internal regulations. Collaborate with the management team to review updates to departmental processes and policy to remain in compliance and audit ready.

Immigration or work visa sponsorship will not be provided for this position

Hiring Compensation Range: $25 - $28 hourly

Compensation may vary based on factors including but not limited to skills, education, location and experience.

In addition to base compensation, associates may be eligible for a scorecard incentive, full range of benefits and generous paid time off. The base salary range is subject to change and may be modified in the future.

As an Equal Opportunity / Affirmative Action Employer, Independent Health and its affiliates will not discriminate in its employment practices due to an applicant's race, color, creed, religion, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship and immigration status, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law. Click here for additional EEO/AAP or Reasonable Accommodation information.

Current Associates must apply internally via the Job Hub app.