QA Audit Manager - Operations - Health First : Job Details

Duties & Responsibilities

• Maintain procedures and programs to ensure Operational units meet organizational and regulatory standards for proper function, quality, and in support of enhancing Member/Provider service experiences.

• Experience applying critical thinking skills and problem-solving approaches in producing analyzing and interpreting reports on trending audit finding results and summarizing details to Operations leadership to address identified areas for improvement.

• Serve as point of escalation for audit disputes.

• Conduct comprehensive needs analysis to ensure that audit programs fulfill the needs and objectives of the company.

• Partner and consult with internal business partners to create and execute audit plans.

• Contribute to creating new processes or services to optimize operational areas.

• Contribute to the overall success of the Quality Assurance service organization by identifying opportunities to continuously improve the learning process and service experience.

• Investigate trends, identify root problems, report issues, and collaboratively work with specific teams/individuals to resolve issues.

• Demonstrate or develop a deep understanding of all Operations processes and supporting systems.

• Manage QA Auditors to conduct process reviews and provide oversight into the creation and execution of audits across multiple operational areas.

• Ensure individuals and the team meet or exceed performance goals.

• Direct employees in matters of quality and inspection.

• Conduct ongoing staff engagements and monthly team meetings.

• Ensure team support and adheres to all improvement initiatives.

• Provide coaching to QA staff based on quality production standards, service results, and develop improvement plans when needed.

• Additional duties as assigned.

MinimumQualifications

• Bachelors degree from an accredited institution

• Experience in Healthcare/Health Plan customer service, operations, vendor management, or claims processing.

• Previous work experience in an auditing function conducting root cause analysis.

• Experience with troubleshooting and process improvement

• Previous experience supervising staff, including recruiting, hiring, and training staff.

• Demonstrated experience developing and performing audit testing; implementing statistics and process control tools; and maintaining effective compliance and corrective action procedures.

• Demonstrated knowledge in creating reports, surveys and quality audits for management, external clients, and Executive leaders.

• Experience communicating with cross-functional individuals within an organization.

• Experience leading project groups and independent projects within a corporate setting.

• Proficient in Microsoft Excel, including experience in creating documents, V-lookups, and pivot tables within Microsoft Excel.

• Proficient experience creating presentations using Microsoft PowerPoint.

• Exposure to corporate email and Microsoft Word by creating and editing documents.

• Experience with troubleshooting and process improvement.

Preferred Qualifications

• Demonstrated experience or deep understanding of healthcare Operations processes and supporting systems such as Claims Processing, Enrollment & Billing, and Member Services.

• 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 managing a Quality Assurance or Operations Audit team.

• Experience working with AI or other machine learning tools to assist with streamlining QA processes.

• Experience working with delegates/vendors in a healthcare insurance setting.

• Demonstrated experience or deep understanding of healthcare Operations processes and supporting systems such as Claims Processing, Enrollment & Billing, and Member Services.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.