The Associate Operational Auditor performs operational audits related to the following operational areas within Fidelis: Member Services, Enrollment, Claims, PDM/CCD, QHCM Behavioral Health Call Center, Authorization Call Center, QHCM Medical Management Team (loading of authorizations from provider e-fax submissions), Credentialing, QHCM Pharmacists, QHCM Pharmacy Technicians, QHCM Behavioral Health Utilization Review, QHCM Behavioral Health Case Management and QHCM clinical reviews. The Auditor performs audit work associated with verifying the accuracy of transactions and compliance with quality standards, along with promoting the organization's service standards; performs audits to determine the integrity and accuracy of regulatory requirements (i.e. Federal, State, County, etc.) as well as departmental Policies & Procedures and provides statistical data and reports as required for various functional areas audited to identify continuous quality improvement opportunities.
Associates Degree required.
3 years of related experience as well as familiarity with the areas being audited.
Knowledge in common audit techniques and methodologies including root cause analysis and risk identification.
Strong working knowledge of Managed Care/Health Insurance concepts and regulations.
Preferred knowledge of government sponsored health insurance programs (i.e. Medicaid, FHP, CHP and Medicare.) as well as within the operational areas under audit.
Must have a working knowledge of Microsoft Office applications as well as the Facets and Cactus systems.
Must possess effective verbal and written communication skills and have demonstrated interpersonal relations skills.
Good working ability to perform sound data analysis and problem solving skills that include making recommendations to change or improve operational processes.
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