HealthEdge dezvoltă tehnologii pentru organizații care finanțează servicii de sănătate prin suita sa de soluții HealthRules. Portofoliul de platforme al companiei include administrarea digitală a dosarelor de despăgubire, fluxuri de lucru pentru gestionarea îngrijirii și integritatea plăților, ajutând planurile de sănătate să conecteze datele operaționale, să automatizeze procesele esențiale, să îmbunătățească acuratețea plăților și să susțină experiențe mai bune pentru membri. Cu un accent pe serviciile medicale și asigurările de sănătate, HealthEdge reunește expertiza în software și consultanță pentru a ajuta organizațiile care finanțează servicii de sănătate să lucreze mai eficient și să coordoneze îngrijirea într-un mod mai eficace.
Enrollment Quality Auditor – Medicaid | HealthEdge (Remote, US)
HealthEdge seeks a remote Enrollment Quality Auditor to review Medicaid enrollment and eligibility transactions. The role covers CMS and state compliance, dual-eligible coordination, and quality-assurance performance.
Statele Unite ale Americii44.000 $ – 50.000 $ / an
RemoteNormă întreagăNivel mediuSeniorLimbă Obligatorie: englezăAuditorDescriere
- Audit enrollment, disenrollment, eligibility, and plan or PCP-change transactions handled by health plan enrollment associates.
- Use customer-defined quality processes and tools for audits and rebuttal reviews.
- Review 834 enrollment files and coordinate with state enrollment systems and enrollment brokers.
- Validate member effective dates, retroactive enrollment or disenrollment, and eligibility segments.
- Check Medicaid eligibility redeterminations and recertifications for accuracy and compliance with CMS and state timeliness standards.
- Audit Medicare-Medicaid coordination for dual-eligible members, including aligned eligibility segments and coordination of benefits.
- Communicate quality-assurance results to associates and partner with Team Leads and managers on feedback.
- Prepare team and individual quality-assurance performance reports for management and associates.
- Advise Training and Team Lead teams on processing guidance and refresher-training needs.
- Take part in Audit the Auditor programs.
- Participate in semiannual or annual auditor calibration sessions.
- Keep current with CMS Medicaid managed-care guidance, state enrollment requirements, and MLTC enrollment and disenrollment rules.
- Present audit findings to client audit teams and operational managers.
Cerințe
- High school diploma or GED is required.
- At least three years of experience in health plan enrollment or eligibility auditing operations is required.
- Experience auditing Medicaid managed-care enrollment is preferred.
- Experience with managed long-term care or dual-eligible Medicare-Medicaid enrollment is strongly preferred.
- Proficiency with Microsoft Office, especially Excel, PowerPoint, and Outlook.
- Experience with HealthRules Payor or GuidingCare is preferred.
- Familiarity with EDI 834 enrollment transactions and eligibility verification systems is a plus.
- Ability to evaluate contractual service-level agreements and KPIs, especially enrollment-processing timeliness.
- Strong communication and collaboration skills for working with a remote team.
- Ability to work independently with limited supervision while contributing effectively in a team setting.
- Completion of a pre-employment criminal background check may be required.
- Must be able to work across multiple time zones.
- Ability to meet physical requirements such as extended sitting or standing at a computer and the required visual demands.
Beneficii
- Remote work environment.
- Hybrid or remote work environment.
- Travel may be required based on company needs.
- Reasonable accommodations are available for individuals with disabilities.
- Commitment to equal opportunity and workforce diversity.