Operations Quality Auditor (Claim)

Role Overview:  The Operations Quality Auditor is responsible for conducting timely, accurate quality reviews of operational functions, including claims processing.

Work Arrangement:

• Remote - This position is fully remote and may be performed from any location within the United States (US), with required availability during Eastern Standard Time (EST) hours.
• Associates must have access to a reliable high‑speed internet connection capable of supporting daily responsibilities, with a minimum bandwidth of 50 Mbps download and 5 Mbps upload. Fully remote associates residing in states where reimbursement is required by contract, law, or regulation may submit for appropriate expense reimbursement.

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.

Education & Experience:

• High School Diploma or GED required.
• 3 years of provider experience in a Medicaid managed care environment required.
• Claims processing knowledge, preferably using the Facets system required.
• Experience in call center operations and member/provider database maintenance preferred.
• Working knowledge of Microsoft Office applications required.

Skills & Abilities:

• 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.