Senior Quality Verification Specialist

Great companies need great teams to propel their operations. Protect member and provider information through independent, second-level quality reviews using an “audit-the-auditor” approach. Your scope includes assessing member and provider interactions related to member and provider account access requests, including portal administrator access changes, and provider Electronic Funds Transfer (EFT) change requests. You’ll report findings, communicate results, and partner with account leaders to drive people, process, and technology improvements, validate corrective actions, and guide Verification Specialists while maintaining review independence. You will be responsible for conducting independent quality and compliance reviews of member and provider interactions involving account access requests and provider EFT change requests. Working closely with Compliance, Operations, Quality, Privacy, Security, and other authorized stakeholders, the reviewer evaluates end-to-end request processing, documents findings, validates corrective actions, and confirms sustained process improvements. The position serves as an objective quality resource, providing clear reporting, risk identification, and compliance guidance while maintaining independence from operational decision-making. Serve as an independent line of defense by evaluating verification activities, identifying risks, and ensuring compliance with established policies, procedures, and controls. Your work helps protect member and provider information, strengthen operational integrity, and support regulatory compliance. Independently reassess completed reviews using an "audit-the-auditor" approach to evaluate the completeness, accuracy, consistency, and appropriateness of prior verification reviews, findings, decisions, and escalations. Apply random, risk-based, targeted, and retrospective review methodologies while retesting controls, documentation, decisions, and handoffs against requirements in effect at the time of processing. Assess member and provider interactions related to account access requests and provider EFT changes, ensuring information accuracy, professional communication, proper authorized representative handling, complete documentation, and compliance with escalation and follow-up requirements. Test high-risk request controls by evaluating request completeness, supporting evidence, signatures, organizational relationships, email and website validations, banking information verification, ownership verification, authorized exceptions, and portal access administration activities. Document review scope, sampling methods, findings, risks, severity, rationale, and recommendations, while presenting results to compliance leadership, business leaders, and process owners. Escalate critical risks immediately , including suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and other significant compliance issues in accordance with established escalation procedures. Validate corrective actions by tracking remediation efforts, supporting root-cause analysis, confirming effectiveness of corrective measures, and escalating overdue or ineffective actions. Leverage audit and quality findings to improve processes, strengthen controls, and support organizational performance through collaboration, coaching, and continuous improvement initiatives. Preserve review evidence by maintaining complete, traceable records tied to original case documentation while adhering to retention, access, and legal hold requirements. Drive people, process, and technology improvements by translating trends and findings into actionable recommendations for training, procedures, workflows, system enhancements, automation opportunities, and control improvements. Guide and develop colleagues by providing evidence-based coaching, supporting onboarding and knowledge sharing, identifying training needs, and recommending updates to procedures, scripts, checklists, and reference materials. Five or more 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 testing across multi-step workflows. Ability to apply policies and procedures, independently reassess completed verification reviews, retest underlying controls and handoffs across the account access and provider EFT change-request lifecycle, reconcile conflicting information, and document objective, evidence-based conclusions. Working knowledge of member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and cross-team handoffs. Strong analytical, organizational, and time-management skills to prioritize high-risk work and meet quality and turnaround requirements. ability to prepare findings reports, present results and risk-based recommendations to leadership and operational teams, guide and coach Verification Specialists, promote consistent review standards, and partner on people, process, and technology improvements. Proficiency with Microsoft Office and SharePoint; ability to use 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 end-to-end reviews of EFT, portal administrator access, or other high-risk provider changes. Experience with independent second-level quality reviews, risk-based sampling across roles and process stages, finding classification, root-cause analysis, corrective-action validation, cross-functional trend reporting, and recommendations for people, process, or technology improvements. Familiarity with CXone or comparable interaction-review platforms, member and provider systems of record, and business-verification tools. Fully remote options from most US locations and territories Video cameras must be used during all interviews, as well as during the initial week of orientation The deadline to submit applications for this posting is November 12, 2026 #LI-Quality Verification Specialist Video is required for screenings and interviews, so please test your camera and microphone in advance. Do not use AI tools, virtual backgrounds/filters, or visual enhancements during the interview. The pay range for this position is $63,000.00 - $90,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors. All salaried, full-time candidates are eligible for our generous, flexible vacation policy, a 401(k) employer match, comprehensive health benefits, and educational assistance. We also have a variety of leadership and technical development academies to help build your skills and capabilities. You’ll be joining a company where collaboration, innovation, and inclusion fuel our growth. Learn more about Gainwell at our company website and visit our Careers site for all available job role openings. Gainwell Technologies is an Equal Opportunity Employer, where all qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical condition), age, sexual orientation, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. Gainwell Technologies defines “wages” and “wage rates” to include “all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits.