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 customer quality procedures and tools for auditing and rebuttal processes.

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

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

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

• Audit coordination for 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 Team Leads and managers to provide constructive feedback.

• Compile and present team and individual quality assurance performance reports to management and associates.

• Contribute to Training and Team Lead teams regarding processing instructions and refresher training.

• Engage in Audit the Auditor initiatives.

• Take part in semi-annual or annual auditor calibration activities.

• Maintain updated knowledge of CMS Medicaid managed care guidelines, state Medicaid enrollment regulations, and MLTC enrollment/disenrollment policies.

• Communicate audit findings to 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.

• Proficient in MS Suite, especially Excel, PowerPoint, and Outlook.

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

• Knowledge of EDI 834 enrollment transactions and eligibility verification systems is advantageous.

• Capability to analyze contractual SLAs and KPIs, particularly concerning enrollment processing timeliness.

• Strong ability to communicate effectively and collaborate with a remote team.

• Ability to work independently with minimal supervision as well as collaboratively in a team setting.

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

• Must be able to work across multiple time zones.

• Must meet physical demands including prolonged sitting and/or standing at a computer, and possess required vision capabilities.

🏝️ Benefits

• Remote work environment.

• Hybrid or remote work options available.

• Travel may be required based on company needs.

• Reasonable accommodations for individuals with disabilities.

• Commitment to equal opportunity and workforce diversity.