Quality Auditor - Health Plan Operations

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do. Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults. Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity. At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve. The Job The Quality Auditor will perform routine and targeted operational quality audits across health plan operations including but not limited to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials to ensure compliance with regulatory requirements, internal policies, contractual obligations, and operational standards. This role monitors quality, accuracy, identifies opportunities for improvements that will enhance member and provider experience. Responsibilities Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials standards for assigned business process. Work assigned cases through SCANs workflow system, and applies correct status attributes to track and trend issues. Notate cases/audits with required detail to ensure that others understand status of case/audit and final resolutions. Work closely with other business units to ensure processing errors are reviewed and corrected. Follow policies and procedures in order to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management; identify and report problems with workflows following proper departmental procedures. Actively participate in departmental staff meetings and training sessions. Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures. Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity and attendance. Escalate appropriate audit issues to management as required and follow departmental/organizational policies and procedures. Maintain required levels of production and quality standards as established by management. Participate in and support ad-hoc audits as needed. Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team through knowledge and idea sharing. Take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers. Contribute to team effort by accomplishing related results as needed. Actively support the achievement of SCAN’s Vision and Goals. Other duties as assigned. Qualifications Associate’s degree preferred or equivalent experience. 3+ years complex auditing processing and/or auditing experience in the health plan, healthcare, or managed care organization with experience in Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials. Must be proficient in processing/auditing for Medicare and Medicaid plans. 3+ years’ experience in managed healthcare environment related to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and Letters/Materials processing/audit processing/audit. Strong organizational, analytical thinking and accounting skills; oral and written communication skills. Strong knowledge of CMS requirements regarding auditing processing. Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience. Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment. Strong PC skills. Microsoft Office (Word, Excel, Outlook, Teams) are required. What’s in it for you? Base wage range: $25.38 to $36.76 per hour. Work Mode: Remote. Annual bonus program. Robust Wellness Program. Generous paid‑time‑off (PTO). Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday. Excellent 401(k) Retirement Saving Plan with employer match and contribution. Robust employee recognition program. Tuition reimbursement. Equal Employment Opportunity At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more. SCAN is proud to be an Equal Employment Opportunity andAffirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, marital status, disability, protected veteran status or any other status protected by law. A background check is required. #J-18808-Ljbffr