Quality Assurance Credentialing Auditor
Location: Milwaukee, Wisconsin US
Job Number: 863
The primary objective of this position is to perform routine and focused audits electronically to identify inaccurate provider enrollment data.
PRIMARY JOB RESPONSIBILITIES: Performs routine and focus audits on Provider Enrollment and Credentialing (PEC) staff to identify inaccurate data. Assess accuracy and consistency of provider enrollment and credentialing data for each Credentialing Staff. Research and trouble-shoot problem areas in data entry in Cactus and Windward and notify Quality Supervisor and PEC management. Identify prevalent trends and recommend immediate resolution techniques to supervisor and management. Provide individual quality feedback to PEC management. Collaborate with other staff and leadership on the use of established business processes, procedures and related tools. Work with Quality Supervisor and PEC leadership team to identify, develop, and implement business processes and tools to improve PEC accuracy results. Work with Quality Supervisor and PEC management to resolve difficult or complex issues, and recommend related training opportunities that improves overall accuracy results. Work with Quality Supervisor and PEC management to develop and implement new or revised business processes as required by enterprise wide or compliance team relating to regulatory changes. Demonstrate proficiency with the principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approach. Adhere to Inter-rater Reliability principles to ensure the audit results generated meet the accepted criteria by quantitatively defining the degree of agreement between two or more auditors. Develop and coordinate the implementation of systems, procedures and forms to improve data collection. Assist in the development of action plans to address quality deficiencies. Other duties as needed or required. Reporting: Produce daily report from Cactus of audits to be performed. Produce weekly, monthly, quarterly and annual management and operations focused reports. Assist in developing and maintaining dashboard to report Corporate and Client Quality results. Other duties as needed or required.
- High School diploma/GED required.
- 2 years of Provider Enrollment and/or credentialing experience in health care industry.
- Ability to analyze, interpret and apply business and operational policies.
- A thorough understanding of dependents, relationship types and eligibility guidelines to ensure consistency in validation of plan participation.
- Demonstrated excellence in data gathering, analysis, reporting and process improvements.
- Ability to make sound decisions.
- Ability to analyze and solve problems.
- Strong interpersonal, written and oral communication skills.
- Proven logic and reasoning skills that apply methods of consistency, validity, soundness and completeness
- In depth knowledge of Windward a plus.
- Strong computer skills.
- Intermediate to Advanced knowledge of Microsoft Excel, Access and Word required.
- Ability to work overtime as needed or required.
- Required to attend additional training as requested/deemed necessary.
- Two to four year College Degree in Healthcare preferred.
- Previous experience in an auditing role a plus.
PHYSICAL DEMANDS: Incumbent must be able to communicate effectively. Requires overall light physical effort (up to 25lbs.) Manual dexterity and sitting is required in carrying out position own position responsibilities (i.e. use of personal computer). Ability to travel or move about within and outside serviced facilities required. Incumbent works primarily in either a private or shared office environment.
At DentaQuest, we believe that everyone should live life free of dental disease. As a purpose-driven, double bottom line company that is improving oral health for everyone, we are transforming the oral health system - from the way we provide care and pay for it, to how we talk about it and prioritize it in our policies and communities.
Meaningful change requires a revolution in oral health. We are redefining what it means to prevent disease and provide better access to care for everyone. We are going beyond the dental chair to reshape the oral health system, addressing total health and the social and cultural factors that impact it.
To make this revolution a reality, we harness our unique reach and insights to advance policy, financing, care, and the community. That means solving problems in a flexible and efficient way, testing and trialing to create new solutions and deliveringmeasurableoutcomes for the people we serve.
The people of DentaQuest have a common purpose, and we work together with passion, perseverance and focus to achieve a nation where no child suffers from the pain of tooth decay. Where adults keep all their teeth for their entire lives. Where every person has access to quality dental care.
Job Number: 2838
Community / Marketing Title: Quality Assurance Credentialing Auditor
Location_formattedLocationLong: Milwaukee, Wisconsin US