Quality Auditor - The Health Plan

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000 dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.  At Texas Children’s Hospital, diversity, equity, and inclusion are at the core of our values and mission for all of the patients and families that we serve. We are committed to providing a diverse and inclusive work environment for all faculty, staff and learners throughout our organization. We believe that each member of our one amazing team provides enrichment that allows us to create a lasting legacy for future employees of this great organization.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Quality Auditor-- someone who works well in a fast-paced setting. In this position, you will be responsible for reviewing and evaluating the quality and effectiveness of the department policies and procedures, processes, and system updates such as member eligibility, provider setup, benefit/contract/edit configuration, and/or code/rate updates. This role will partner with the department managers on audit findings to ensure identified errors are promptly and appropriately corrected, as well as identified performance and/or training gaps are addressed. The Quality Audit also tracks and reports quality metrics for the department and serves as the department's point of contact for audit inquiries.

 

Think you’ve got what it takes?

Responsibilities :

Job Duties & Responsibilities

• Review and evaluate the quality, accuracy, and timeliness of system updates such as member eligibility, provider setup, benefit/contract/edit configuration, and/or code/rate updates
• Create a tracking and reporting mechanism for audits to be able to share findings with the department managers and assist with identifying performance and training gaps
• Develop and track quality metrics for the department that are reported to leadership on a routine basis and incorporated into the departmental dashboard
• Identify and report 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
• Develop and maintain policies and procedures for the departmental audit program

Qualifications:

Skills & Requirements

• High school diploma or GED required
• Bachelor’s degree in healthcare administration, business administration, computer science or related field preferred
• 2 years Medicaid Managed Care experience required
• 4 years health plan operations experience required
• 4 years health plan payer systems/applications experience required
• 2 years auditing/quality/review/training experience preferred
• Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.

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