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Healthfirst · 2 days ago

QA Financial Auditor II

United States

Full-time

Remote

Mid Level

$69K/yr - $100K/yr

Healthfirst is a healthcare organization seeking a Quality Assurance Financial Auditor II to perform audits of financial processes. The role involves conducting quality audits, mentoring junior auditors, and participating in process improvement projects to ensure compliance and mitigate financial risk.

Commercial InsuranceHealth CareHealth InsuranceInsurance

Responsibilities

Conduct moderately complex to complex quality audits of provider claims, pre-payments and post-payments including high-dollar and specialized claims across multiple lines of business, claim types and products

Audit the work of more junior auditors and identify opportunities for coaching and//or training

Identify and communicate issues identified through audits and recommended solutions relevant to business operations

Assist management in preparing departmental reports policies and procedures

Mentor and coach Financial and//or Operations QA auditors

Participate as a Subject Matter Expert on various process improvement projects designed to meet departmental and operational needs

Assist with performing User Acceptance Testing (UAT) on system enhancements or corporate projects in partnership with Business Operations

Analyze errors and determine root causes for appropriate classification

Record//track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network

Review and investigate claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst policy and procedure

Prepare written reports concerning investigation activities and present results of investigations to senior staff

Complete subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations

Review the accuracy and efficiency of existing training materials

Qualification

Audit experienceRoot cause analysisAdvanced ExcelSQLICD10 certificationWritten communicationVerbal communicationProblem solvingConfidential information handlingMentoring

Required

Audit experience with the investigation, determination and reporting of financial processes

Work experience in Microsoft Office suite of applications including advanced Excel (formatting formulas, managing data, filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations)

Experience conducting root cause analysis in an auditing capacity

Experience conducting analytical work and providing creative ideas for problem solving

Work experience requires written and verbal communication that is clear, concise, grammatically correct, and professional

Experience handling confidential information

Associate degree from an accredited institution

Preferred

Bachelor's degree from an accredited institution

Audit experience with the investigation, determination and reporting of financial processes specifically around Healthcare Claims Adjudication and Claims Processing

Ability and willingness to handle increasing workload and responsibility

Willingness and ability to learn and evaluate new information, both technical and procedural

ICD10 certification

Basic foundation of SQL, Tableau, and SharePoint

Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, Child Health Plus