Enrollment Quality Auditor
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Job Description
Enrollment Quality Auditor auditing Medicaid enrollment and eligibility transactions for HealthEdge’s health insurance technology platform. Reviewing CMS/state compliance, dual-eligible coordination, and QA performance.
Responsibilities:
- Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates
- Follow customer quality processes and tools for audit and rebuttal activities
- Review enrollment (834) file transactions and coordinate with state enrollment systems and enrollment brokers
- Confirm accuracy of member effective dates, retroactive enrollment/disenrollment, and eligibility segments
- Verify timely and accurate Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards
- Audit dual-eligible Medicare-Medicaid enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits
- Share QA results with associates and coordinate with Team Leads and managers to provide feedback
- Compile and report team and individual QA performance to management and associates
- Provide input to Training and Team Lead teams for processing instructions and refresher training
- Participate in Audit the Auditor programs
- Participate in semi-annual or annual auditor calibration activities
- Maintain current knowledge of CMS Medicaid managed care guidelines, state Medicaid enrollment requirements, and MLTC enrollment/disenrollment rules
- Report audit findings to client audit teams and operational managers
Requirements:
- High School Diploma or GED required
- 3 years health plan enrollment/eligibility auditing operations experience required
- Medicaid managed care enrollment auditing experience preferred
- Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience strongly preferred
- Proficiency in MS Suite, specifically Excel, PowerPoint and Outlook
- HealthRules® Payor or GuidingCare® experience preferred
- Familiarity with EDI 834 enrollment transactions and eligibility verification systems a plus
- Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness
- Ability to effectively communicate and collaborate with a remote team
- Ability to work independently with limited supervision and collaboratively in a team environment
- Candidates may be required to complete a pre-employment criminal background check
- Must work across multiple time zones
- Ability to meet physical demands including prolonged sitting and/or standing at a computer, and required vision abilities
Benefits:
- Remote work environment
- Hybrid or remote work environment
- May require travel dependent on company needs
- Reasonable accommodations for individuals with disabilities
- Equal opportunity and workforce diversity commitment
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