Quality Auditor

JOB SUMMARY

The Quality Auditor protects insurance inventory by ensuring compliance with operational procedures, processes, training and regulations. The position audits and trains newly-hired and tenured employees to ensure quality work for clients in the Insurance Department. The Quality Auditor utilizes industry best practices and insurance knowledge to assess performance and training opportunities, ensuring inventory is resolved with accurate and prompt interventions. They work closely with department leadership and trainers to identify education topics and trends amongst users.

ESSENTIAL FUNCTIONS

• Ensures compliance with established operational procedures and processes, by examining accounts, reports, processes, and documentation.
• Ensures inventory is meeting best practice and client service level agreements.
• Completes random and targeted audits on large samples to gather accurate data by user, team, client, and department. Compiles findings appropriately.
• Completes audits on adjustment submissions to review write-off trends for accurate and aggressive insurance follow-up measures.
• Maintains current internal and operational processes and quickly pivots if and when new workflows are adopted. Helps communicate changes and recommends subsequent new operational workflows based on audit trends.
• Works in conjunction with department leadership to target high-impact workflow opportunities found in audits. Prioritizes efforts by compliance, revenue, and client satisfaction.
• Provides supporting documentation and details for leadership to effectively communicate audit results to users. Maintains historical data.
• Advises leadership of any workflow items requiring immediate attention.
• Work closely with leadership in system placement concerns and trends in regards to inventory assigned in the Insurance Department.
• Utilizes training evaluations to evaluate effectiveness of any training provided, to include onboarding.
• Identifies and addresses training deficiencies, and bring significant concerns to the attention of the department leadership and trainers.
• Displays deep knowledge of insurance follow-up and payer guidelines, basic analytics, and attention to detail. Must show objectivity and discretion when conducting audits.

TEAM FUNCTIONS (To be performed when not actively involved in performing actions under “ESSENTIAL FUNCTIONS”)

• Observe and analyze Insurance department activities for process improvement and increased resolution enhancement.
• Review training curriculum and documentation to identify inconsistencies in workflows.
• Identify missed opportunities for additional recovery attempts

KNOWLEDGE, SKILLS, AND ABILITIES

• Professional presentation skills with clear verbal communication, proper grammar and articulation.
• Excellent listening, interpersonal, and teamwork skills.
• Attention to detail and thoroughness. P:\Dept Information & JDs\Insurance\Quality Auditor.docx
• Deep understanding of system and operational workflows regarding insurance follow-up, with emphasis on Epic foundation configurations.
• Ability to work independently with minimal direction or oversight.
• Ability to navigate multiple systems and sources of information.
• Basic reporting and Excel experience.
• Must be flexible with time depending on business and training needs

EDUCATION AND EXPERIENCE

• Minimum 2 years in hospital revenue cycle.
• Minimum 1 year (12 months) of direct insurance follow-up or denials resolution.
• Minimum 1 year (12 months) employment at PFS Group, currently in good standing for productivity, quality, and attendance.
• Experience in Epic Resolute for Hospital Billing strongly preferred; Epic Resolute for Professional Billing can be substituted.

PREFERENCES

• Experience with quality audits or quality reviews.
• Experience with CUBS workflows and reporting tools