Senior Quality Verification Specialist

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

📋 Description

• Perform independent, second-tier quality and compliance evaluations utilizing an “audit-the-auditor” methodology.

• Reevaluate completed verification assessments and reexamine evidence, controls, decisions, and transitions.

• Assess member and provider interactions related to account access requests and provider EFT modification requests.

• Implement random, risk-based, focused, and retrospective review methodologies.

• Revalidate identity, representative authority, affiliation, ownership, authentication, call-control, disclosure, and documentation criteria.

• Analyze request completeness, corroborative evidence, signatures, organizational relationships, email and website validations, banking details, ownership, authorized exceptions, and portal access management.

• Document review scope, sampling strategies, findings, risks, severity, reasoning, and recommendations.

• Communicate results to compliance leadership, business executives, and process stakeholders.

• Promptly escalate suspected fraud, privacy or security issues, unauthorized modifications, systemic control failures, and significant compliance concerns.

• Monitor remediation efforts, assist in root-cause analysis, verify corrective measures, and escalate overdue or ineffective responses.

• Maintain comprehensive, traceable review documentation in accordance with retention, access, and legal hold protocols.

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

• Mentor Verification Specialists, facilitate onboarding and knowledge sharing, identify training requirements, and propose updates to procedures and reference materials.

• Assist with authorized operational verification and follow-up activities while ensuring separation from reviews of the same cases.

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

⛳️ Requirements

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

• Capability to implement policies and procedures, independently reassess completed verification reviews, retest fundamental controls and handoffs throughout the account access and provider EFT modification lifecycle, reconcile conflicting information, and document objective, evidence-based findings.

• Proficient understanding of member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and cross-departmental handoffs.

• Strong analytical, organizational, and time-management capabilities.

• Excellent written and verbal communication skills; ability to prepare findings reports, present results and risk-based recommendations, mentor and guide Verification Specialists, and collaborate on improvements.

• Proficient in Microsoft Office and SharePoint.

• Competent in utilizing case-management systems, approved records repositories, and interaction-recording or quality-review platforms.

• Preferred: Experience in Medicaid member services or provider operations, quality reviews related to account access and provider EFT modification requests, or comprehensive assessments of EFT, portal administrator access, or other high-risk provider changes.

• Preferred: Experience with independent second-level quality reviews, risk-based sampling, finding classification, root-cause analysis, corrective-action validation, cross-functional trend reporting, and recommendations for enhancements.

• Preferred: Familiarity with CXone or similar interaction-review platforms, member and provider systems of record, and business-verification tools.

• Video cameras must be utilized during interviews and the initial week of orientation.

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

🏝️ Benefits

• Work flexibility.

• Opportunities for learning and career advancement.

• Flexible vacation policy.

• 401(k) employer matching.

• Comprehensive health benefits.

• Educational assistance.

• Leadership and technical development academies.

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