Job Description
Operations Quality Audit Analyst
Lead I – BPM
Who We Are
UST HealthProof is a dynamic company with a mission to lower the cost of care and deliver the future of healthcare. Our consumer-centric approach gives our health plan customers a modern infrastructure and reduced administrative costs, helping to drive better business results for our customers — and better outcomes for our communities.
We achieve this mission together through teamwork, communication, collaboration, and focus. Our employees are our greatest assets, and we invite you to apply to be a part of our journey toward making a difference in healthcare in the United States. **
You Are**
Perform production and quality audits to ensure operations are effective, consistent, and in compliance with business rules and CMS processing standards. The primary focus includes but is not limited to auditing all functions across Back Office Operations. This auditing activity is essential to support and proactively analyze internal and CMS audit readiness **
The Opportunity**
- Completes quality audits across all functions of Back Office Operations, reviewing completed work in comparison to established documented procedures to determine accuracy
- Complies and reports all audit activity and results weekly to the leadership team
- Providers monthly assessment and analysis of audit results
- Identify training opportunities based on quality assessment results
- Conducts reviews of DLPs across functional areas for accuracy of information and instruction.
- Collaborates with each Operations manager to build and execute specific functional audit plans for Claims, Configuration, Appeals and Grievances, and Billing and Enrollment functions.
- Perform audit-related investigations to troubleshoot error trends as they relate to business processes and/or training.
- Coordinates the impact of regulatory changes and updates to policies, practices, and procedures and works closely with managers and stakeholders to appropriately translate the updates to the end user.
- Reviews, evaluates, and makes recommendations for process improvements.
- Assists in the creation of departmental procedures and reference documents.
- Participates in projects as assigned.
- May be responsible for researching operational audit best practices and making recommendations for improvement.
- Maintains confidentiality of all information processed.
This position description identifies the responsibilities and tasks typically associated with the performance of the position. Other relevant essential functions may be required. **
What You Need**
- Bachelor’s degree or equivalent experience.
- Background in insurance, business, or a related field.
- A combination of relevant education and work experience may be considered in lieu of a degree
- 3 to 5 years of relevant work experience can experience working in a corporate environment, preferably in a healthcare environment and/or internal audit experience.
- Experience working in a government program (Medicare and Medicaid) preferred or three (3) or more years experience in an insurance organization which provides working knowledge in one or more of the following areas: claims management, underwriting, finance or auditing; insurance education coursework.
- Certification or progress toward certification in courses focused on but not limited to Quality Auditor, Quality Manager, Six Sigma, or other quality designations is highly preferred and encouraged
- Working knowledge of CMS guidance and business area development procedures, workflows, and rules for multiple states.
- Excellent analytical skills to identify opportunities for improvement and recommend solutions.
- Strong analytical and problem-solving skills.
- Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information, and respond to questions as appropriate.
- Ability to read, analyze, and interpret policy documents, technical, legal, and financial information, and procedure manuals.
- Excellent verbal and written communication skills.
- Ability to manage multiple projects and meet necessary deadlines.
- Basic knowledge of computers, spreadsheet software, and word processing and the ability to enter accurately 50 WPM.
- Ability to perform mathematical calculations.
- Ability to proofread documents for accuracy of spelling, grammar, punctuation, and format and edit as necessary.
- Ability to maintain confidentiality.
- Ability to create surveys and survey criteria.
- Completion of industry-recognized quality or internal audit certification(s).
- Advanced knowledge of industry best practices related to sound internal controls and audit techniques.
- Ability to assist in the development and implementation of policies, practices, and procedures.
Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience. As required by local law, UST provides a reasonable range of compensation for roles that may be hired in California, Colorado, New York, or Washington as set forth below. **
Role Location: Remote
Compensation Range:** $42,000-$64,000
Our full-time, regular associates are eligible for 401K matching, and vacation accrual and are covered from day 1 for paid sick time, healthcare, dental, vision, life, and disability insurance benefits. **
What We Believe**
We’re proud to embrace the same values that have shaped UST HealthProof since the beginning. Since day one, we’ve been building enduring relationships and a culture of integrity. And today, it's those same values that are inspiring us to encourage innovation from everyone, to champion diversity and inclusion, and to place people at the center of everything we do. **
Humility**
We will listen, learn, be empathetic and help selflessly in our interactions with everyone. **
Humanity**
Through business, we will better the lives of those less fortunate than ourselves. **
Integrity**
We honor our commitments and act with responsibility in all our relationships. **
Equal Employment Opportunity Statement**
UST HealthProof is an Equal Opportunity Employer.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.
UST HealthProof reserves the right to periodically redefine your roles and responsibilities based on the requirements of the organization and/or your performance.
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