Performance Quality Audit III (US)
Elevance Health

Job Info

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Responsible for evaluating the quality of services and interactions provided by organizations within the enterprise. Included are processes related to enrollment and billing and claims processing. Primary duties may include, but are not limited to: Evaluates the quality and accuracy of claims transactions and/or communications with providers, groups, and/or policyholders. Identifies, documents, and reports any transaction errors or communications issues in a timely manner to ensure prompt resolution. Tracks and trends audit results, providing feedback to management. Identifies and reports on systemic issues which create ongoing quality concerns. Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested. Produces other ad hoc reports as requested by internal and external clients. Provides training, mentoring and support to quality staff. Associates at this level function as subject matter experts, conducting routine to complex audits, generally related to multiple functions on multiple systems platform for multiple lines of business. Works proactively and independently including facilitation of calibration sessions with clients and/or teams. Requires high school diploma or equivalent (GED); minimum 5 years experience or any combination of education and experience which would provide an equivalent background.. Working knowledge of insurance industry and medical terminology, and in-depth knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred. Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred, and WGS claims system knowledge is required.

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