Operations Quality Auditor (Claim)

Role Overview: The Operations Quality Auditor is responsible for conducting timely, accurate quality reviews of operational functions, including claims processing.

Work Arrangement:

• Remote - This position is fully remote and may be performed from any location within the United States (US), with required availability during Eastern Standard Time (EST) hours.

• Associates must have access to a reliable high‑speed internet connection capable of supporting daily responsibilities, with a minimum bandwidth of 50 Mbps download and 5 Mbps upload. Fully remote associates residing in states where reimbursement is required by contract, law, or regulation may submit for appropriate expense reimbursement.

Responsibilities:

• Identify system and/or operational issues that impact the achievement of established quality performance standards.

• Analyze audit results to determine root causes of errors or trends affecting quality outcomes.

• Provide clear issue identification, problem analysis, and recommendations for resolution or process improvement to management.

• Accurately document audit findings, trends, and observations within designated quality tracking tools.

• Support quality improvement initiatives by sharing insights and contributing to corrective action strategies as needed.

Education & Experience:

• High School Diploma or GED required.

• 3 years of provider experience in a Medicaid managed care environment required.

• Claims processing knowledge, preferably using the Facets system required.

• Experience in call center operations and member/provider database maintenance preferred.

• Working knowledge of Microsoft Office applications required.

Skills & Abilities:

• Strong attention to detail with the ability to accurately review and assess operational work.

• Solid understanding of claims processing workflows and quality standards within a Medicaid environment.

• Ability to identify trends, analyze issues, and communicate findings clearly and effectively.

• Strong written documentation skills, with the ability to clearly record audit results and observations.

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.