Senior Quality Verification Specialist

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

📋 Description

• Perform independent quality and compliance assessments of member and provider interactions related to account access requests and provider EFT change requests.

• Re-evaluate completed verification reviews utilizing an “audit-the-auditor” methodology.

• Reassess evidence, controls, decisions, documentation, and transitions from intake and authentication through verification, approval, processing, communication, escalation, and closure.

• Implement random, risk-based, targeted, and retrospective review strategies.

• Reassess controls that support identity, representative authority, affiliation, ownership, authentication, verification responses, call controls, scripts, disclosures, and documentation standards.

• Evaluate account access requests and provider EFT changes for accuracy, professionalism in communication, handling by authorized representatives, completeness of documentation, escalation, and adherence to follow-up compliance.

• Test controls for high-risk requests, including supporting evidence, signatures, organizational relationships, email and website validations, banking information, ownership verification, exceptions, and portal access management.

• Create evidence-based reports detailing scope, sampling methods, findings, risks, severity, rationale, and recommendations.

• Share results with compliance leadership, business leaders, and process stakeholders.

• Promptly escalate any suspected fraud, privacy or security issues, unauthorized changes, systemic control breakdowns, and significant compliance concerns.

• Monitor remediation efforts, assist in root-cause analysis, validate the effectiveness of corrective actions, and escalate overdue or ineffective measures.

• Ensure comprehensive, traceable review evidence is maintained in line with retention, access, and legal hold requirements.

• Transform trends and findings into actionable recommendations for training, procedures, workflows, system enhancements, automation, and control improvements.

• Mentor Verification Specialists, support onboarding and knowledge-sharing initiatives, identify training needs, and suggest updates to procedures, scripts, checklists, and reference materials.

• Assist with approved verification tasks and operational follow-ups while ensuring separation from reviews of the same cases.

• Uphold objectivity, avoid conflicts of interest, and refer cases with direct involvement to an independent reviewer.

⛳️ Requirements

• A minimum of five years of experience in member services, member or provider verification, provider enrollment, healthcare operations, compliance operations, or a similar field, including quality reviews or operational control testing across multi-step workflows.

• Capability to apply policies and procedures, independently reassess completed verification reviews, retest underlying controls and transitions throughout the account access and provider EFT change-request lifecycle, reconcile conflicting information, and document objective, evidence-based conclusions.

• Familiarity with member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and inter-departmental transitions.

• Strong analytical, organizational, and time management abilities.

• Excellent written and verbal communication skills; capable of preparing findings reports, presenting results and risk-based recommendations to leadership and operational teams, guiding and mentoring Verification Specialists, promoting consistent review standards, and collaborating on improvements in people, processes, and technology.

• Proficient in Microsoft Office and SharePoint.

• Ability to utilize case-management systems, approved records repositories, and interaction-recording or quality-review platforms.

• Experience in Medicaid member services or provider operations, quality reviews of member and provider interactions related to account access and provider EFT change requests, or comprehensive reviews of EFT, portal administrator access, or other high-risk provider changes (preferred).

• Background in independent second-level quality reviews, risk-based sampling, finding classification, root-cause analysis, validation of corrective actions, cross-functional trend reporting, and recommendations for enhancements in people, processes, or technology (preferred).

• Knowledge of CXone or similar interaction-review platforms, member and provider systems of record, and business-verification tools (preferred).

• Video cameras are required to be used during all interviews and throughout the first week of orientation.

• A photo will be taken during screening for verification throughout all stages of the recruitment process.

• Must participate in screenings, interviews, and meetings from a quiet location with a reliable internet connection.

🏝️ Benefits

• Fully remote options available from most locations and territories in the US.

• Flexible work arrangements.

• Opportunities for learning and career development.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.