Quality Auditor - Managed Care Medicaid

 
Position: Quality Auditor - Managed Care Medicaid

Job ID: 150072

Location: US-TX-Bellaire

Department: TCHP - BUSINESS OPERATIONS

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a -5p

About Texas Children's Hospital

Texas Children’s Health Plan (TCHP) is the largest Texas Medicaid managed care organization, and is part of the Texas Children’s healthcare system. Founded in 1996, TCHP is the nation's first health maintenance organization (HMO) created just for children and pregnant women. Our plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area. Currently the Health Plan serves more than 450,000 members across three service areas (Harris, Jefferson, North East). Members of the plan receive care from our network of more than 4,000 primary care physicians, 8,000 specialists, and 110 hospitals. They can also receive care at The Center for Children and Women, a patient and family-centered medical home with two convenient locations for TCHP members who can have all their medical needs met in one place, receiving multiple services the same day. TCHP is a recognized leader at encouraging holistic care that empowers families to live healthier lives. To join our community of 13,000 dedicated team members, visit www.texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at www.infinitepassion.org

Summary:

We are searching for a Quality Auditor - someone who works well in a fast-paced setting. In this position, you’ll review and evaluate the quality and effectiveness of the business operations department’s policies, procedures, processes, and system updates as they relate to member eligibility, provider setup, benefit/contract/edit configuration, and code/rate updates. You will also partner with managers on audit findings to ensure any identified errors are promptly and appropriately corrected, as well as any performance and/or training gaps are addressed. Finally, you will track and report quality metrics for the department and serve as the point of contact for audit inquiries.

 

Think you’ve got what it takes?



Responsibilities :

  • Collaborate with managers for eligibility, provider setup, and medical policy/configuration to develop an audit program to review and evaluate the quality, accuracy, and timeliness of system updates
  • Clearly and concisely report audit findings on a frequent basis to managers and assist with identifying performance and training gaps for the team
  • Ensure errors are identified and corrected quickly
  • Create a tracking and reporting mechanism for audits and share findings with the managers
  • Develop and track quality metrics for the department and report to leadership on a regular basis
  • Develop and maintain policies and procedures for the departmental audit program
  • Identify and report the process improvement opportunities for the department to increase efficiencies, performance, and quality
  • Assist with the production of various reports regarding the department’s quality and performance


Qualifications:

  • High school diploma or GED
  • Bachelor’s degree in health care administration, business administration, computer science, or related field preferred
  • 2 years’ experience in Medicaid managed care, 4 years’ experience in health plan operations, and 4 years’ experience in health plan payor systems/applications
  • 2 years’ experience in auditing/quality review/training preferred


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