Quality Verification Specialist

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

📋 Description

• Perform secondary evaluations of completed verification tasks for member and provider account access requests, as well as provider Electronic Funds Transfer (EFT) modification requests.

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

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

• Assess interactions, documentation, and verification results for thoroughness, consistency, and adherence to compliance standards.

• Ensure that authentication and information-protection controls have been properly implemented.

• Return any incomplete or unsupported requests to the submitting teams for necessary corrections.

• Document rationale for decisions and outline subsequent steps required.

• Detect discrepancies, potential fraud, and privacy or security issues.

• Temporarily halt affected work, preserve evidence, and adhere to escalation and communication protocols.

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

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

• Collaborate with compliance liaisons, account leaders, and process owners regarding recurring issues, root-cause analysis, and approved enhancements.

• Provide updates on progress and obstacles while honoring account-specific requirements.

• Partner with Senior Verification Specialists on procedural guidance, calibration, and quality assessments.

• Execute corrective actions and supply evidence for independent validation.

• Assist with onboarding, training, and knowledge sharing initiatives.

• Suggest updates to procedures and resources and direct policy inquiries and exceptions to compliance authorities.

⛳️ Requirements

• High school diploma or equivalent is required.

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

• Experience in reviewing documentation, resolving discrepancies, or applying approval and escalation criteria is essential.

• Capability to implement procedures, assess completed verification tasks, identify gaps, and make evidence-based decisions on approvals, denials, or escalations.

• Familiarity with confidential information protection, indicators of fraud, and escalation protocols is necessary.

• 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, organizational skills, and time management capabilities are required.

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

• Proficiency in Microsoft Office and SharePoint is essential.

• Competence in utilizing case-management, records, and interaction platforms.

• Preferred: At least three years of relevant experience.

• Preferred experience in Medicaid member or provider operations, account access review, provider EFT change review, or other high-risk request decisions.

• Preferred background in reviewing identity, representative authority, provider applications, or financial supporting documentation.

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

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

🏝️ Benefits

• Flexible work arrangements.

• Opportunities for learning and career advancement.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefit packages.

• Educational assistance programs.

• Leadership and technical development academies.