Quality Verification Specialist

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

📋 Description

• Perform secondary evaluations of finalized verification tasks for member and provider account access requests as well as provider EFT change requests.

• Analyze supporting documentation and approve, deny, or escalate requests within the limits of delegated authority.

• Review identity verification, representative authority, and necessary controls in accordance with approved account procedures.

• Assess interactions, documentation, and verification outcomes for thoroughness, consistency, and compliance.

• Ensure that authentication and information-protection protocols were adhered to and return any incomplete or unsupported requests for revision.

• Document the rationale for decisions and outline necessary next steps, securing separate operational, privacy, compliance, or business-owner approvals when required.

• Detect discrepancies, suspected fraud, and any privacy or security issues.

• Halt any affected work, preserve evidence, and adhere to escalation and communication protocols.

• Convey outcomes, requirements for missing information, and subsequent steps to submitting agents.

• Maintain secure, precise, and traceable case records, original evidence, and audit trails.

• Collaborate with compliance liaisons, account leaders, and process owners to identify recurring problems and implement enhancements.

• Assist in root-cause analysis, corrective measures, procedural guidance, calibration, onboarding, training, and knowledge dissemination.

• Suggest updates to procedures and resources, and refer policy inquiries and exceptions to the appropriate compliance authorities.

⛳️ Requirements

• High school diploma or equivalent qualification.

• A minimum of two years of experience in member or provider services, provider enrollment, healthcare operations, verification, quality assurance, compliance operations, or a related field.

• Experience in reviewing documentation, resolving discrepancies, or utilizing approval and escalation criteria.

• Capability to implement procedures, evaluate completed verification tasks, identify gaps, and make evidence-based decisions regarding approvals, denials, or escalations within delegated authority.

• Familiarity with confidential-information protection, fraud indicators, and escalation procedures.

• Ability to learn and apply account-specific identity and representative verification requirements, account access safeguards, and provider EFT controls.

• Strong attention to detail, sound judgment, effective organization, and time management skills.

• Excellent written and verbal communication skills with the ability to collaborate across compliance, quality, and account teams.

• Proficiency in Microsoft Office and SharePoint, as well as case management, records, and interaction platforms.

• Preferred: A minimum of three years of relevant experience.

• Preferred experience in reviewing identity, representative authority, provider applications, or financial supporting documents.

• Preferred familiarity with member and provider systems, verification tools, and secure case documentation.

• Preferred experience with quality findings, corrective actions, root-cause analysis, training, or cross-account process improvements.

• Ability to participate in screenings, interviews, and meetings from a quiet location with stable internet connection.

• Video camera required during interviews and the initial orientation week.

🏝️ Benefits

• Work flexibility.

• Opportunities for learning and career development.

• Flexible vacation policy.

• 401(k) employer match.

• Comprehensive health benefits.

• Educational assistance.

• Access to leadership and technical development academies.