Operations Quality Auditor (Claim)

Summary

AmeriHealth Caritas is recruiting an Operations Quality Auditor to conduct timely and accurate quality reviews of operational functions, including claims processing. The role identifies and analyzes quality issues, documents audit findings, and supports process improvement and corrective action initiatives in a fully remote work arrangement.

Responsibilities

• Identify system and/or operational issues that impact the achievement of established quality performance standards
• Analyze audit results to determine root causes of errors or trends affecting quality outcomes
• Provide clear issue identification, problem analysis, and recommendations for resolution or process improvement to management
• Accurately document audit findings, trends, and observations within designated quality tracking tools
• Support quality improvement initiatives by sharing insights and contributing to corrective action strategies as needed

Skills

• High School Diploma or GED
• 3 years of provider experience in a Medicaid managed care environment
• Claims processing knowledge, preferably using the Facets system
• Working knowledge of Microsoft Office applications
• Strong attention to detail with the ability to accurately review and assess operational work
• Solid understanding of claims processing workflows and quality standards within a Medicaid environment
• Ability to identify trends, analyze issues, and communicate findings clearly and effectively
• Strong written documentation skills, with the ability to clearly record audit results and observations
• Experience in call center operations and member/provider database maintenance

Qualifications

Must Haves

• High School Diploma or GED
• 3 years of provider experience in a Medicaid managed care environment
• Claims processing knowledge, preferably using the Facets system
• Working knowledge of Microsoft Office applications
• Strong attention to detail with the ability to accurately review and assess operational work
• Solid understanding of claims processing workflows and quality standards within a Medicaid environment
• Ability to identify trends, analyze issues, and communicate findings clearly and effectively
• Strong written documentation skills, with the ability to clearly record audit results and observations

Nice to Haves

• Experience in call center operations and member/provider database maintenance

Benefits

• Fully remote work arrangement, which may be performed from any location within the United States (US), with required availability during Eastern Standard Time (EST) hours.
• Associates residing in states where reimbursement is required by contract, law, or regulation may submit for appropriate expense reimbursement.