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Kompaniyadagi ish o‘rinlari

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.

USAmerika Qo‘shma Shtatlari
44 000 $ – 50 000 $ / yil
MasofaviyTo‘liq stavkaO‘rta darajaSeniorTalab Qilinadigan Til: inglizchaAuditor

Tavsif

  • 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.

Talablar

  • 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.

Imtiyozlar

  • 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.

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