Provider Network Quality Assurance Specialist

This is a fully remote position, open to applicants in North Carolina.

📋 Description

• Oversee, evaluate, and enhance the quality, accuracy, and compliance of provider network operations.

• Assist in ensuring provider data integrity, adherence to regulations, accuracy of provider directories, and ongoing process enhancements.

• Execute quality audits on provider network operations processes.

• Create and uphold an audit schedule.

• Conduct research, analyze data, and propose solutions for administrative, organizational, and operational challenges.

• Maintain audit evidence and records to ensure readiness for both internal and external reviews.

• Assess the accuracy of provider directories and uphold documentation that meets DHB and NCQA standards.

• Compare published information with source systems and coordinate outreach or research to address discrepancies.

• Prioritize corrections that impact member access, search results, or regulatory compliance.

• Execute root cause analysis, monitor corrective actions, and report outcomes.

• Review provider data within Salesforce, Alliance Claims System, and enrollment and contracting systems.

• Confirm contract terms, effective dates, network participation, locations, and reimbursement attributes.

• Identify and direct missing, expired, inconsistent, duplicate, or incorrect information and oversee corrections until completion.

• Maintain audit criteria in accordance with regulatory, accreditation, contractual, and internal policy requirements.

• Document compliance gaps, evaluate risk, and escalate significant findings.

• Support regulatory obligations, accreditation assessments, and internal compliance evaluations.

• Collaborate with accountable teams to outline corrective and preventive actions, designate owners, set milestones, and establish due dates.

• Record all root cause analyses.

⛳️ Requirements

• Bachelor’s Degree in human services; Sociology, Psychology, Public Health, Statistics, Economics, Business Administration or a related social science field from an accredited institution.

• Minimum of five (5) years of relevant experience in quality assurance/improvement activities.

• Proven experience leading project teams focused on quality improvement initiatives.

• Proficiency in Excel is required for data analysis and the creation of graphs and tables.

• Excellent communication and writing abilities.

• Strong organizational and time management capabilities.

• Advanced knowledge of Microsoft Office applications, especially Excel.

• Proficiency in MicroStrategy or other statistical or data modeling software.

• Experience in developing quality improvement plans for services addressing complex physical health, behavioral health, and social determinants of health needs.

• Familiarity with project management processes.

• Capacity to manage multiple projects simultaneously.

• Ability to engage with members, network providers, families, and government personnel while being mindful of cultural differences.

• Previous experience in Managed Care is preferred.

🏝️ Benefits

• Medical, Dental, Vision, Life, and Long Term Disability insurance.

• Comprehensive retirement savings plan.

• Flexible work schedules, including options for hybrid or remote work.

• Paid time off encompassing vacation, sick leave, holidays, and management leave.

• Dress code flexibility.