Enrollment Quality Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct audits on enrollment, disenrollment, eligibility, and plan/PCP change transactions carried out by health plan enrollment associates.

• Adhere to the customer quality process and utilize tools for auditing and rebuttal.

• Analyze enrollment (834) file transactions and liaise with state enrollment systems and enrollment brokers.

• Validate the accuracy of member effective dates, retroactive enrollment/disenrollment, and eligibility segments.

• Ensure timely and precise processing of Medicaid eligibility redeterminations and recertifications in accordance with CMS and state Medicaid timeliness standards.

• Audit the coordination of dual-eligible Medicare-Medicaid enrollment, including the alignment of Medicare and Medicaid eligibility segments and coordination of benefits.

• Share quality assurance results with associates and collaborate with operational Team Leads and managers to provide constructive feedback.

• Gather, compile, and present team and individual quality assurance performance to management and associates.

• Offer insights to Training and Team Leads regarding processing instructions and refresher training requirements.

• Engage in Audit the Auditor programs.

• Participate in semi-annual or annual auditor calibration activities.

• Stay updated on CMS Medicaid managed care enrollment guidelines, relevant state Medicaid enrollment requirements, and MLTC enrollment/disenrollment rules.

• Report to the Lead Auditor or Quality Audit Manager and interact daily with client audit teams and operational managers.

⛳️ Requirements

• A High School Diploma or GED is mandatory.

• A minimum of 3 years of experience in health plan enrollment/eligibility auditing operations is required.

• Experience in Medicaid managed care enrollment auditing is preferred.

• Strong preference for candidates with managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience.

• Proficiency in MS Suite, particularly Excel, PowerPoint, and Outlook is essential.

• Experience with HealthRules® Payor or GuidingCare® is preferred.

• Familiarity with EDI 834 enrollment transactions and eligibility verification systems is a plus.

• Capability to analyze contractual SLAs and KPIs, especially regarding enrollment processing timeliness.

• Ability to communicate effectively and collaborate with a remote team.

• Capacity to work independently with minimal supervision and collaboratively in a team setting.

• Candidates may need to undergo a pre-employment criminal background check.

🏝️ Benefits

• Flexible remote work environment.

• Potential travel may be required based on company needs.

• Reasonable accommodations for individuals with disabilities.

• Equal opportunity employer dedicated to fostering workforce diversity.