QA Auditor - Appeals & Grievances - Remote

Job Purpose

The QA Auditor performs audit functions across Client Teams to determine operational efficiency, adherence to internal processes and procedures as well as regulatory requirements, and achievement of quality standards. This role requires an in-depth understanding of the denials management process, a clinical background, attention to detail, and the ability to effectively assess the quality of work completed. The QA Auditor will work closely with internal teams to provide feedback, maintain high standards of quality, and ensure compliance with established processes.

Duties & Responsibilities

• Conduct regular audits of work performed by appeal writers and automated processes to ensure adherence to internal policies and quality standards in the denials management process
• Evaluate how denials are handled, ensuring that all necessary steps are followed, documentation is accurate, and appropriate actions are taken. Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals
• Offer constructive feedback to appeal writers based on audit results, identifying areas for improvement and providing guidance on corrective actions. Provide feedback on automated processes to ensure the highest levels of efficiency in overturning denials
• Maintain accurate records of audit findings and track trends or recurring issues in the denials management process. Prepare reports to share with management and relevant teams.
• Develop strategies for business performance improvement initiatives, including includes: identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports
• Utilize and navigate multiple internal systems (e.g., claims processing systems, communication tools) to review audit data and provide feedback. Adapt to new systems as necessary
• Work closely with appeal writers, managers, and other stakeholders to foster a collaborative approach to quality improvement and process optimization
• Additional duties as assigned
• Use, protect and disclose patients' protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards

• Understand and comply with Information Security and HIPAA policies and procedures at all times
• Limit viewing of PHI to the absolute minimum as necessary to perform assigned duties

Qualifications

• State Licensed RN is required
• Experience working in a healthcare or insurance environment, particularly with claims and denials management
• Familiarity with common claims management and denial resolution systems
• Experience in quality auditing or process improvement initiatives
• Familiarity with MCG and Interqual guidelines and processes
• Strong understanding of the denials management process, including common causes of denials and strategies for resolution.
• Prior experience with medical records review, claims processing, utilization/case management in a clinical practice or managed care organization, Clinical Appeal Writer, etc.
• Advanced knowledge of Microsoft Word, Excel, and Teams for communication, data analysis, and reporting
• Ability to quickly learn and effectively navigate multiple software systems, providing accurate and timely feedback
• Strong analytical skills with the ability to detect issues, inconsistencies, and areas for improvement in the denials management process
• Ability to manage multiple audits simultaneously while maintaining accuracy and efficiency
• Strong interpersonal skills, ability to communicate well at all levels of the organization
• Strong problem solving and creative skills and the ability to exercise sound judgment and make decisions based on accurate and timely analyses
• High level of integrity and dependability with a strong sense of urgency and results oriented
• Excellent written and verbal communication skills required
• Gracious and welcoming personality for customer service interaction

Working Conditions

• Ability to travel to client sites on occasion
• Ability to work outside of normal business hours as needed
• Physical Demands: While performing the duties of this job, the employee is occasionally required to move around the work area; Sit; perform manual tasks; operate tools and other office equipment such as computer, computer peripherals and telephones; extend arms; kneel; talk and hear.
• Mental Demands: The employee must be able to follow directions, collaborate with others, and handle stress.
• Work Environment: The noise level in the work environment is usually minimal.

Med-Metrix will not discriminate against any employee or applicant for employment because of race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), parental status, national origin, age, disability, genetic information (including family medical history), political affiliation, military service, veteran status, other non-merit based factors, or any other characteristic protected by federal, state or local law.