Manager Quality Auditing

2 weeks ago

Philadelphia, United States AmeriHealth Caritas Full time

Your career starts now. We are looking for the next generation of health care leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

**Responsibilities**:
The primary purpose of the Manager, Quality Auditing Analyst is to provide leadership and direction of operational auditing for the following functions across the enterprise and covers approximately 1200+ associates: claims, contact center, enrollment, and provider maintenance. The scope of this role is operational quality auditing for the abovementioned functions across the enterprise’s portfolio of product lines, health plans, and other potential projects and product types.
- Responsible for driving strategic planning within the Quality team, resource planning, production forecasting and tracking, and implementation of Quality Initiatives as required.
- Ensuring the completion of all compliance audits as required. This includes the Member Touchpoint Measures (MTM) audits for all branded BCBS plans as required by the BCBSA.
- Coordinate the monthly completion and reporting the results of enterprise operations audits for each function in the company - claim, call center, enrollment processing.
- Coordinate and report the daily results of the performance management audits - claim, call center, enrollment and provider maintenance.
- Coordinate and execute the completion of all high dollar and other pre-disbursement audits to reduce rework and improve claim accuracy.
- Recommend and execute target audits as needed or requested.
- Support all new business through claim pre-adjudication validation process until business has reached stabilization.
- Provide support and analysis to service operations during internal and external audits.
- Accountable for the development and direct performance of the Quality Auditing team.
- Coordinate corrective action plans with service operations using audit trending data to improve overall claim, call, provider maintenance and enrollment quality.

**Education/Experience**:

- Minimum of 1 to 2 years of call center experience.
- 5-10 years claim processing and/or claims auditing experience in a Healthcare environment required; preferably in a Medicaid HMO environment.
- Bachelor’s Degree preferred.
- Minimum 2 years using Microsoft Access for reporting, development and analysis.
- Strong managerial experience required with prior experience leading and managing large teams.
- In-depth claims processing knowledge required.
- Computer proficiency in Microsoft Word, PowerPoint, Excel, Access, Project.
- Reporting experience preferred.

**Diversity, Equity, and Inclusion**

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

**Our Comprehensive Benefits Package**

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

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