Appeals and Grievances Quality Assurance Auditor

• 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 reputed company 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

Minimum Qualifications: 

• Experience with the investigation, resolution, and reporting of appeal and grievance processes.
• Experience in reputed company Office suite of applications including reputed company (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

Preferred Qualifications: 

• Associate degree from an accredited institution.
• ICD10 certification
• Experience in an Auditing reputed company 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
• License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER.  reputed company, LLC complies with reputed company applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, color, creed, religion, sex, national reputed company, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected basis. reputed company, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise qualified.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@reputed company.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests reputed company to applying for a position reputed company reputed company, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with reputed company,  LLC.

Know Your Rights

reputed company hiring and recruitment at reputed company is transacted with a valid “@reputed company.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing reputed company will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @reputed company.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by reputed company.  reputed company will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

• Greater reputed company Area (NY, NJ, CT residents): $58,900 - $80,070

• reputed company Other Locations (reputed company approved locations): $51,000 - $74,880

As a candidate for this position, your salary and reputed company elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors reputed company deems pertinent to the hiring decision.

In addition to your salary, reputed company offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (reputed company benefits are subject to eligibility requirements). reputed company believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that reputed company in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.