Quality Assurance Auditor - Government Programs

PHSO Quality Assurance Auditor - Government Programs | AdventHealth Corporate

Location Address: 485 N Keller Rd, Maitland, FL 32751

Top Reasons to Work at AdventHealth Corporate

• Great benefits
• Immediate Health Insurance Coverage
• Career growth and advancement potential

Work Hours/Shift:

• Full-Time, Monday – Friday

You Will Be Responsible For:

• Performs routine quality audits and reporting as required by government program guidelines.
• Maintains knowledge of all state and federal regulations and guidance pertaining to all aspects of government programs, such as ACOs, MSSPs, DC programs, MA plans, PCF programs and more.
• Develops standard operating procedures and metrics to support government program auditing.
• Responsible for annual execution of Monitoring and Auditing plans.
• Develops audit processes to evaluate outside entities who have delegated entity responsibilities.
• Evaluates problem audit results and provides appropriate and timely guidance to PHSO leadership. Evaluates government program requirements and ensures compliance within the team, with external teams, and with providers.
• Evaluates and documents internal audit findings, prepares preventive or corrective action plans and processes, and monitors to completion.
• Serves as a subject matter expert on regulatory guidelines between customers and PHSO  leadership  for administrative sensitive issues.
• Coordinates reporting needs to support government programs.
• Identifies training needs, develops and organizes training interventions to meet quality assurance standards.

What You Will Need:

Education and Experience Required:

• Bachelor’s degree in a related field, such as Business, marketing, or Communications, etc. AND
• A minimum of three years of experience in an ACO, health plan, or CIN sufficient to yield the knowledge requirements above OR
• A minimum of eight years of experience in an ACO, health plan, or CIN sufficient to yield the knowledge requirements above

Education and Experience Preferred:

• Master’s degree in a related field, such as Business Administration, Healthcare Administration, or Public Administration

Licensure, Certification or Registration Required:

• Certified Quality Auditor CQA OR the qualifications and ability to earn within 3 months
• Certified Associate in Project Management (CAPM) or Project Management Professional (PMP) preferred

Knowledge and Skills Required:

• Working knowledge of all aspects of a typical ACO, health plan, CIN, value-based programs, health system, or physician practice including customer service, network management, data exchange, claims processing, sales and underwriting, marketing, benefit plan design, medical management, quality management, finance, risk adjustment, regulatory oversight, and compliance.
• Working knowledge of auditing benefits, objectives, tools, strategies, data collection, analysis, reporting and corrective actions plans.
• High-level interpersonal skills. Able to work collaboratively and tactfully with multi-disciplinary and diverse teams across department lines, management levels, and business entities.
• High degree of emotional intelligence and self-management ability. Able to remain calm, focused, and productive in stressful situations, conflicts.
• Excellent analytical and problem-solving skills
• Effective oral and written communication skills, with the ability to articulate complex information in understandable terms to all levels of staff.
• Effective computer skills, particularly Microsoft Office Outlook, Word
• Proficient Microsoft Excel skills, including accurate sorting and filtering, VLOOKUP's, Pivot Tables. 
• Ability to work in a matrix-management environment to achieve organizational goals
• Excellent reasoning, problem solving, prioritization and business judgement.

Job Summary:

The Government Programs Quality Assurance (QA) Auditor reports to the Population Health Services Organization (PHSO) Director of Government Programs. The QA Auditor ensures the processes associated with government programs meet compliance with federal and state regulations as well as AdventHealth best practice standards. Programs may include Accountable Care Organizations (ACOs), Medicare Shared Savings Programs (MSSPs), Direct Contracting (DC) programs, Medicare Advantage (MA) programs, Primary Care First (PCF) programs, and Comprehensive Primary Care Plus (CPC+) programs. Processes may include provider and staff rosters, public reporting, provider contracting, incentive payout distributions, board and committee compensation, provider education completion, board of managers composition, board and committee agreements, medical director record-keeping, quality measure reporting, consumer and provider communications, compliance plans, meeting minutes, benchmark recalculations, CMS performance reporting, and data-sharing requests. The QA Auditor is responsible for developing, maintaining, adhering to, auditing and reporting on systems and policies and procedures for all quality assurance activities that promote company and agency compliance.

This position is responsible for developing and maintaining training materials and developing processes and procedures utilized for auditing within and interfacing with the Government Programs team. He/she objectively evaluates and measures the performance of the staff and team to ensure efficiency and maintain standard operations that complies with all regulatory guidelines and is leveraged for optimization. Identifies and reports on process improvement opportunities to the Director. Actively seeks to model the achievement of excellence. Promotes teamwork by personally adopting principles of caring and integrity. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.