Quality Auditor

About Texas Children's Hospital

Summary:

We are searching for a Quality Auditor - Benefits, Contracts, Fee Schedules Configuration/Testing - someone who works well in a fast-paced setting. In this position, you’ll review and evaluate the quality and effectiveness of the business operations department’s policies, procedures, processes, and system updates as they relate to member eligibility, provider setup, benefit/contract/edit configuration, and code/rate updates. You will also partner with managers on audit findings to ensure any identified errors are promptly and appropriately corrected, as well as any performance and/or training gaps are addressed. Finally, you will track and report quality metrics for the department and serve as the point of contact for audit inquiries. If your title currently is Automation Tester, Test Architect or Test Engineer you may be a fit for this position.  

In this position, we are searching for someone who can audit Medicaid Provider configurations/data. The ideal candidate for this role is someone with strong Medicaid Provider configuration or previous experience managing provider data. Experience with QNXT/Epic Tapestry and a previous background in medical claims is also a plus. This role will also include providing training to staff to improve compliance with the department quality metric goals. 

Qualifications

Being fully vaccinated against COVID-19 is required for all employees at Texas Children’s, unless approved for a medical or religious exemption. 

• High school diploma or GED 
• Bachelor’s degree in health care administration, business administration, computer science, or related field preferred 
• 2 years’ experience in Medicaid managed care 
• 4 years’ experience in health plan operations, and 4 years’ experience in health plan payor systems/applications 
• 2 years’ experience in auditing/quality review/training preferred 

Responsibilities

• Design and execute QA tests for System Updates, Databases and Software Applications, Eligibly and Enrollment, Provider Setup, Benefits Coding, Contracts, Fee schedules, and Claim Editing Rules.

• Identify bugs and quality issues in development, service, or business processes.

• Business Requirements: Works with project team and peers to understand customer needs. 

• Develop & Implement: Collaborate with managers for eligibility, provider setup, and medical policy/configuration to develop an audit program to review and evaluate the quality, accuracy, and timeliness of system updates. 

• Production Support: Helps to troubleshoot defects and or enhancements to systems and software. Tracks performance and production issues. Escalates production issues as appropriate. 

• Quality Assurance: Clearly and concisely report audit findings on a frequent basis to managers and assist with identifying performance and training gaps for the team. Ensure errors are identified and corrected quickly.

• Quality Metrics: Develop and track quality metrics for the department and report to leadership on a regular basis. 

• Process Improvement and Reporting: Identify and report the process improvement opportunities for the department to increase efficiencies, performance, and quality. Assist with the production of various reports regarding the department’s quality and performance. 

• Process, Policies, and Standards: Develop and maintain policies and procedures for the departmental audit program. 

• Customer service: Works with QA manager to keep customers informed about any quality issues. Tracks and reports on issues and enhancement requests for the business in a timely manner. 

• Research/ Evaluation: Analyzes and tests new releases/versions of software. May participate in vendor evaluations.