The role of Claims and Quality Management System Auditor is a vital role for Your Hearing Network (YHN). This role reports directly to the Sr. Manager of Operations. Duties and responsibility entail the ability to develop and adhere to company quality assurance principles, identify and execute training needs, and collaborate with internal teams to analyze system requirements and claims coding. The role will also support sister companies, AudioNet America and Birdsong Hearing Benefits.  This role will support auditing submitted claims, patient files, and processed claims. The role will oversee the training delivery, providing on-the-job training (OJT) and post-training support through developing appropriate and through training material and programming to support annual quality training.
 
The auditing function requires a detailed-oriented oversight of quality control processes. The role will develop testing parameters, review processes to industry standards, and assess procedures. Training of other staff and sharing detailed results with the executive team, are required of this role.

Key Accountability Metrics
- Plan, coordinate, develop and implement approved projects in order to enhance the overall efficiency of operational procedures, methods, controls and performance.
- Responsible for compiling and reporting any accuracy errors found while auditing up to various levels of leadership.
- Provide leadership team with status of projects; issue, communicate and recommend policy decisions to achieve project objectives.
- Perform special audits of provider payments for payers as requested by regulators, contracting, and internal management.
- Represent department as requested on work groups and special assignments, including related testing.
- Requires knowledge of claims processing for HCFA.
- Function as subject matter expert specific to the audit function and claims.
- Identify documentation or delivery defects and gaps presenting recommendations as required.
- Maintain SOP’s for all auditing procedures/policies and review on a regular basis.
- Work closely with management and supervisory staff and other subject matter experts to develop training and/or documentation needs.
- Develop and implement quality control audit plans.
-  Identify testing parameters for auditing purposes and validity.
- Assign team members to quality audits and oversee their work, if applicable.
- Train employees on quality standards and procedures.
- Ensure that processes comply with industry standards.
- Document defects and recommendations for improvement.
- Prepare and present quality audit reports to senior management.
- Keep abreast of industry standards and regulations.
- Utilize up-to-date technical skills to navigate through electronic leadership tools and platforms; with the ability to test new tools as required.
- Perform analytical claims/call issue review to develop training opportunities
- Develop SOP/Desk-level procedures to ensure quality outcomes.
- Be responsible for overseeing policy and procedure review and completing full/complex desk or pre-delegation, annual or follow-up onsite audits/assessments of delegated entities, including vendors, in support of the regulatory, CMS and NCQA requirements.
- Research, investigate and oversee delegated entity’s compliance with reporting requirements by tracking the receipt and evaluating the completeness of reports.
- Provide highly complex analyses and define efficiencies in relation to compliance programs and internal controls.
- Collaborate on regulatory audits, and findings responses.
- Assist in the development of delegation policies and procedures and associated staff training.
- Assist in the development of audit tools, correspondence templates, etc. to external entities.
- Conduct thorough assessments and audits of processes, procedures, and documentation to ensure alignment with established quality standards, regulatory requirements, and organizational objectives.
- Initiate and maintain cooperative relationships with co-workers, managers and supervisors, claimants, and members of the public.
- Performs increasingly difficult office audits of claims and other business records and documents to determine or verify compliance with laws and regulations.
- Maintains, records, and submits written reports concerning cases and activities.
- Perform other duties as assigned

Requirements and Must Have Criteria
- Four (4) years’ experience which must include specified years of experience specific to claims administration, quality assurance and/or auditing functions.
- Proven experience in group presentations, leading and/or involvement in special projects, preparation of employees for job responsibilities through conducting OJT, performance evaluation feedback, coaching, etc.
- Ability to design and produce training materials based on the Instructional Design Process.
- Demonstrated attention to detail for auditing practices, clear, consistent communication and
- Knowledge of Adult Learning Principles.
- Good verbal and written communication skills.
Other Personal Characteristics and Experience
- Demonstrate an entrepreneurial spirt
- Willingness to go above and beyond daily to achieve best in class results
- Ability to work with highly detailed, complex and emotionally sensitive information.
- Ability to maintain a high degree of discretion, confidentiality, protection, and integrity.
- Ability to learn complex processes, medical terminology, technology systems, and progressively develop data analytics skill set.
- Ability to prioritize and complete multiple complex work assignments.
- Ability to work independently.
- Understand minimal medical terminology.
- Excellent written and verbal communication skills.
- Ability to provide constructive feedback in a clear, concise, and respectful manner.
- Demonstrated ability to meet deadlines.
- Knowledge of quality assurance, quality systems, internal auditing, and/or quality improvement preferred.
- Basic knowledge of data analysis, statistics, data integrity, and analytics with initiative and ability to further develop skills.
Education
 
Bachelor’s degree in education, Instructional Design, Communications or related discipline is preferred or equivalent work experience
 
This role works remotely. You will need the following when working from home:
- Reliable and secure Internet Service Provider at home (no public WiFi) for duration of working hours
- Sufficient room to set up a laptop, monitors, keyboard and mouse
- Comfortable space to work for duration of working hours
- Quiet, private and secure space in which to work
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