Quality Auditor - Med Policy, Fee Schedules, Benefits, and Contracts

 
Position: Quality Auditor - Med Policy, Fee Schedules, Benefits, and Contracts

Job ID: 150993

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

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.

Summary:

We are searching for a Quality Auditor - Med Policy, Fee Schedules, Benefits, and Contracts - 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.

 

For this position, we are searching for someone who can audit configurations for fee schedules, benefits, and contracts for Managed Care. The ideal candidate for this role is someone with strong configuration experience or previous experience auditing Managed Care configuration. Experience with QNXT and a previous background in Medicaid claims is also a plus. This role will also include providing training to staff to improve compliance with the department quality metric goals

 

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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