1 Opening
Taguig
Role description
SUMMARY
Perform production and quality audits to ensure operations are effective, consistent and in compliance with business rules and CMS processing standards. Primary focus includes but is not limited to auditing of all functions across Back Office Operations. This auditing activity is essential to support and proactively analyze internal and CMS audit readiness.
RESPONSIBILITIES/TASKS
Completes quality audits across all functions of Back Office Operations, reviewing completed work in comparison to established documented procedures to determine accuracy
Complies and reports all audit activity and results weekly to leadership team
Providers monthly assessment and analysis of audit results
Identify training opportunities based on quality assessment results
Conducts reviews of DLPs across functional areas for accuracy of information and instruction
Collaborates with each Operations manager to build and execute specific functional audit plans for Claims, Configuration, Appeals and Grievances and Billing and Enrollment functions
Perform audit related investigation to troubleshoot error trends as it relates to business processes and/or training
Coordinates the impact of regulatory changes and updates to policies, practices and procedures and works closely with managers and stakeholders to appropriately translate the updates to the end user
Reviews, evaluates, and makes recommendations for process improvements
Assists in the creation of departmental procedures and reference documents
Participates in projects as assigned
May be responsible for researching operational audit best practices and making recommendations for improvement
Maintains confidentiality of all information processed
QUALIFICATIONS
Bachelor's degree or equivalent experience. Combination of relevant education and work experience may be considered in lieu of a degree
Background in insurance, business, or a related field
3 to 5 years of relevant work experience (can be experience working in corporate environment, preferably in health care and/or internal audit)
Experience working in government programs (Medicare and Medicaid) preferred, or 3+ years experience in an insurance organization which provides working knowledge in one or more of the following areas: claims management, underwriting, finance or auditing; insurance education coursework
Certification or progress toward certification in courses focused on but not limited to Quality Auditor, Quality Manager, Six Sigma, or other quality designations is highly preferred and encouraged
SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED
Working knowledge of CMS guidance and business area development procedures, workflows, and rules for multiple states
Excellent analytical skills to identify opportunities for improvement and recommend solutions
Strong analytical and problem-solving skills
Ability to effectively exchange information clearly and concisely, present ideas, report facts and other information, and respond to questions as appropriate
Ability to read, analyze and interpret policy documents, technical, legal and financial information, and procedures manuals
Excellent verbal and written communication skills
Ability to manage multiple projects and meet necessary deadlines
Basic knowledge of computers, spreadsheet software, and word processing and ability to enter accurately 50 WPM
Ability to perform mathematical calculations
Ability to proofread documents for accuracy of spelling, grammar, punctuation and format and edit as necessary
Ability to maintain confidentiality
Ability to create surveys and survey criteria
Completion of industry recognized quality or internal audit certification(s)
Advanced knowledge of industry best practices related to sound internal controls and audit techniques
Ability to assist in the development and implementation of policies, practices, and procedures
Skills
Client Relationship Management,Team Management,Relationship Building
About UST
UST is a global digital transformation solutions provider. For more than 20 years, UST has worked side by side with the world's best companies to make a real impact through transformation. Powered by technology, inspired by people and led by purpose, UST partners with their clients from design to operation. With deep domain expertise and a future-proof philosophy, UST embeds innovation and agility into their clients organizations. With over 30,000 employees in 30 countries, UST builds for boundless impacttouching billions of lives in the process.
