Quality Auditor for Appeals & Grievances

Job Summary

To ensure compliance and quality improvement, the full-time remote Quality Auditor for Appeals & Grievances will conduct audits of appeals and grievances cases, analyze results for trends, and provide training and guidance to leadership.

Key responsibilities

• Conduct routine and targeted audits of appeals and grievances cases for compliance with regulatory and organizational requirements
• Analyze audit results to identify trends, compliance risks, and opportunities for improvement, preparing reports for leadership
• Partner with leadership to address audit findings and implement corrective action plans while participating in quality improvement initiatives

Required qualifications

• Bachelor's degree or equivalent experience in a related field
• 5 years of work experience in Appeals & Grievances within a health plan environment
• Background in processing, reviewing, or auditing Appeals and Grievances cases
• Knowledge of regulatory requirements related to Appeals and Grievances, including CMS and NCQA standards
• Experience in developing and implementing audit best practices and quality standards