Quality Audit Professional for Grievance amp Appeals

Profile

Description

The Quality (Non-Calls) Professional 2 ensures that products meet certain standards of quality. The Quality (Non-Calls) Professional 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Responsibilities

Hours for this position are Mon-Fri, 8am-5pm EST, with occasional overtime as necessary to meet the needs of the business.

The Quality Audit Professional 2 audits quality of letter, keyed entries from billing and enrollment data.

Analyze Grievance/Appeals case information to ensure compliance of all CMS regulations and contractual guidelines.

Responsible for the review of written communication provided to members

Reviews case documentation to assess appropriate system entries have been thoroughly completed to mitigate risk associated with external audit reviews.

Responsible for driving accuracy and quality assurance, compliance to all established policies and procedures, and sound documentation for all activities.

Serve as a subject matter expert and make process recommendations.

Checks quality cases built by other associates to ensure highest level of quality.

Follows established guidelines/procedures.

Required Qualifications

2 years of Grievance & Appeals/Auditing experience.

Must be bilingual English/Spanish with ability to speak read and write in both languages without limitations or assistance.

Excellent computer skills and ability to easily navigate multiple applications

Ability to work independently under general instructions and with a team

Preferred Qualifications

Bachelor's Degree

Experience with Medicare and Medicaid

Work-At-Home Requirements

Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

Satellite and Wireless Internet service is NOT allowed for this role.

A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com