Quality Assurance Financial Auditor II

• Conduct moderately complex to complex quality audits of provider claims, pre-payments and post-payments including high-dollar and specialized claims across multiple lines of business, claim types and products
• Audit the work of more junior auditors and identify opportunities for coaching and/or training
• Identify and communicate issues identified through audits and recommended solutions relevant to business operations
• Assist management in preparing departmental reports policies and procedures
• Mentor and coach Financial and/or Operations QA auditors
• Participate as a Subject Matter Expert 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 Business Operations
• 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
• Prepare written reports concerning investigation activities and present results of investigations to senior staff
• Complete subsequent auditing and handling of specific claims and appeal requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations
• Review the accuracy and efficiency of existing training materials

• Audit experience with the investigation, determination and reporting of financial processes
• Work experience in Microsoft Office suite of applications including advanced Excel, Word, PowerPoint
• Experience conducting root cause analysis in an auditing capacity
• Experience conducting analytical work and providing creative ideas for problem solving
• Work experience requires written and verbal communication that is clear, concise, grammatically correct, and professional
• Experience handling confidential information
• Associate degree from an accredited institution

• Bachelor’s degree from an accredited institution
• Audit experience with the investigation, determination and reporting of financial processes specifically around Healthcare Claims Adjudication and Claims Processing
• Ability and willingness to handle increasing workload and responsibility
• Willingness and ability to learn and evaluate new information, both technical and procedural
• ICD10 certification
• Basic foundation of SQL, Tableau, and SharePoint
• Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, Child Health Plus

medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions