Provider Network Quality Assurance Specialist
New
J
JobgetherHealthcare managed care
Must reside in North Carolina to meet the position's remote-work requirementsFull-TimeSenior
Salary69,592 - 88,729 USD per year
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Job Details
- Experience
- At least five years of relevant experience performing quality assurance or quality improvement activities.
- Required Skills
- Data AnalysisSalesforceMicrosoft ExcelMicrosoft OfficeQuality Assurance
Requirements
- Bachelor's degree from an accredited college or university in Human Services, Sociology, Psychology, Public Health, Statistics, Economics, Business Administration, or a related social science field.
- At least five years of relevant experience performing quality assurance or quality improvement activities.
- Demonstrated experience leading project teams focused on quality improvement initiatives.
- Advanced proficiency in Microsoft Office applications, particularly Excel, including analyzing data and creating graphs and tables.
- Strong analytical and problem-solving skills, including identifying discrepancies and trends, conducting root cause analyses, and developing recommendations.
- Written and verbal communication skills to prepare audit documentation, summarize findings, and communicate corrective actions.
- Organizational and time management skills to manage multiple projects, competing deadlines, and accurate records.
- Experience with MicroStrategy or other statistical analysis, reporting, or data modeling tools is preferred.
- Experience developing quality improvement plans for services supporting individuals with complex needs is an advantage.
- Familiarity with project management methodologies and processes is desirable.
- Prior managed care experience is preferred.
Responsibilities
- Develop and maintain an audit schedule for provider network operations.
- Conduct audits and maintain evidence and records for internal reviews, external audits, regulatory assessments, and accreditation requirements.
- Evaluate provider directory accuracy and document findings and follow-up activities in accordance with DHB and NCQA requirements.
- Compare directory listings and system records with source documentation, and coordinate research and provider outreach to resolve discrepancies.
- Review provider records across Salesforce, the Alliance Claims System (ACS), enrollment documentation, and contracting systems.
- Verify contract terms, effective dates, network participation, service locations, and reimbursement attributes.
- Route discrepancies to appropriate teams, monitor progress, and track corrections through resolution.
- Document compliance gaps, assess risks, and support regulatory and accreditation information requests.
- Conduct root cause analyses and partner with teams on corrective and preventive action plans.
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