QA Auditor: Appeals and Grievances (Remote) - RN or LPN

The QA Auditor performs audit functions across Client Teams to determine operational efficiency, adherence to internal processes and procedures as well as regulatory requirements, and achievement of quality standards. This role requires an in-depth understanding of the denials management process, a clinical background, attention to detail, and the ability to effectively assess the quality of work completed. The QA Auditor will work closely with internal teams to provide feedback, maintain high standards of quality, and ensure compliance with established processes.

Audit Denials Management Processes: Conduct regular audits of work performed by appeal writers and automated processes to ensure adherence to internal policies and quality standards in the denials management process. Review and Analyze Denials: Evaluate how denials are handled, ensuring that all necessary steps are followed, documentation is accurate, and appropriate actions are taken. Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals. Provide Feedback and Recommendations: Offer constructive feedback to appeal writers based on audit results, identifying areas for improvement and providing guidance on corrective actions. Provide feedback on automated processes to ensure the highest levels of efficiency in overturning denials. Documentation and Reporting: Maintain accurate records of audit findings and track trends or recurring issues in the denials management process. Prepare reports to share with management and relevant teams. Develops strategies for business performance improvement initiatives. This includes: identifying opportunities for improvement, problem prioritization, and creating performance improvement plans for non-compliant audits and/or reports System Navigation: Utilize and navigate multiple internal systems (e.g., claims processing systems, communication tools) to review audit data and provide feedback. Adapt to new systems as necessary. Collaborate Across Teams: Work closely with appeal writers, managers, and other stakeholders to foster a collaborative approach to quality improvement and process optimization. Additional duties as assigned