Sr QA Auditor- Claims (Work Location Flexible, Remote & Hybrid), New York, NY

Created 10/06/2021
Reference 1119255
Job type Full Time
State NY
City New York
The Senior Quality Assurance Auditor is responsible for performing Internal Quality Assurance Audits of Operational processes for internal employees and outsourced vendors to ensure compliance with policies, procedures and quality standards. The incumbent will investigate, audit, conduct root cause analysis, handle processing of determinations, track and trend findings. The individual at this level will embody Healthfirst's Culture Drivers through his/her workplace behavior and works under minimal supervision.

The incumbent will investigate, audit, conduct root cause analysis, handle processing of determinations, track, and trend findings. The individual at this level will embody Healthfirst's Culture Drivers through his/her workplace behavior and works under minimal supervision.
  • Conduct quality audits of provider claims, pre and post paymentsutilizing appropriate sources of information; including eligibility, enrollment, state contracts, provider and facility contracts, and state and health plan billing manuals Analyze errors and determine root causes for appropriate classification.
  • Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network.
  • Review and investigate claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and HealthFirst Policy and Procedure.
  • Present results of investigations to senior staff and is required to prepare written reports concerning investigation activities.
  • Subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.
  • Identify defects and improve departmental performance by supporting quality, operational efficiency, and production goals.
  • Assist in the development of departmental policies and procedures; reviews the efficiency of existing training.
  • Meet established time frames and rates of performance for the quality and quantity of work for the position.
  • Conduct an audit on the auditors for coaching and training opportunities
  • Identifies and communicates issues raised, offering recommended solutions relevant to business and risk
  • Assist Supervisor in preparing departmental reports as needed
  • Mentor and coach QA auditors
  • Participate as a team member on various process improvement projects designed to meet departmental and operational needs
  • Assist with performing User Acceptance Testing (UAT) on system enhancements or corporate projects in partnership with Claims Operations

  • Experience with the investigation, determination, and reporting of claims processes.
  • Experience in Microsoft Office suite of applications including Excel (formatting formulas, managing data, and filtering results), Word (creating and editing documents), PowerPoint (creating and editing presentations) .
  • High School Diploma or GED

Preferred Qualifications:
  • Associate degree from an accredited institution.
  • ICD10 certification
  • Experience in an Auditing capacity conducting root cause analysis
  • Knowledge of at least two or more lines of business such as Medicare NY/NJ, Medicaid, Family Health Plus, Child Health Plus, NH Family
  • Experience handling confidential information.

Please note: Since we care so greatly about our employees' and members' wellbeing, Healthfirst is moving to an environment where our employees are fully vaccinated against COVID-19. As a prospective new team member, you must be fully vaccinated with a CDC/FDA approved COVID-19 shot(s) to work in our offices. If you are selected to interview for this role, we will explain our vaccination policy in further detail and ensure you are comfortable moving forward with this company policy.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement

All hiring and recruitment at Healthfirst is transacted with a valid "" email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.
Employer Healthfirst Inc.

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