Quality Audit Representative – National Remote Job 2024 Full Time

You’ll enjoy the flexibility to telecommute* from anywhere within the U.S. as you take on some tough challenges.

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data, and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits, and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Operation side- community care network. Conducting Quality audit calls on the customer service reps (CSR are taking calls from veterans, providers within CCN). Calls can cover a variety of topics (referral network, provider status within network, urgent care referrals within network). Audit listens to call and score based on guided instructions. Audit 30+ calls per week and assist with other audits i.e. appeals, grievances,. Accurately entered into the system from claims forms entered. Listening to phone calls through out the day and scoring calls. SMEs or supervisor. 25% outside of audit, business process improvement plans, projects, updating work instructions and documentations, developing PP, quick reference guides to be used by auditors to aide in auditing process, calibration sessions to ensure alignment in business processes. Big on training, and increasing transferrable skills, always for training in various areas of operations.. Opportunities for growth within team (Selling to candidates). Daily audit checks performed on QA reviewed and conducted by SME. MAP rating goal is 95% accuracy. Open position due to promotion into next level role within operations

This position is full-time (40 hours/week) Monday – Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8am – 4:30pm EST, 7:00am-3:30pm CST, PST would be negotiable. It may be necessary, given the business need, to work occasional overtime.

We offer 2-4 weeks of paid training. The hours during training will be 8am to 4:30pm EST, 7:30-3:30 CST. If PST, will discuss shift once offered. Training will be conducted virtually from your home.

• All Telecommuters will be required to adhere to UnitedHealth Group’s Telecommuter Policy.

Primary Responsibilities:

• Conduct customer service call audits and appeals and grievance audits
• Provide coaching feedback in relation to audits
• Evaluates customer interactions in accordance within monitoring program guidelines
• Provide suggestions for work institution updates
• Participates in or facilitates bi-weekly calibration sessions to ensure inter-rater reliability
• Conducts other program related process audits as requested
• Plans, prioritizes, organizes and completes work to meet established objectives.
• Analyze current customer service processes and identify gaps or defects to improve overall effectiveness
• Define/recommend process improvements to meet current and future customer service needs/standards
• Perform Quality audits and analyze results to determine process improvement opportunities
• Demonstrate understanding of applicable Customer Service Quality requirements/ guidelines (e.g., escalation procedures, use of SMEs)
• Adhere to established Quality processes, procedures, requirements and guidelines, and ensure adherence by all applicable stakeholders
• Demonstrate knowledge of call-flow processes/procedures (e.g., established quality definitions, guidelines)
• Monitor audit reports/results and provide feedback as needed to drive/validate audit effectiveness
• Audit determinations about whether a claim should have been approved or denied based on available analyses/research of claims information
• Demonstrate knowledge of appeals and grievance processes/procedures

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma / GED
• 2+ years call center customer service experience or equivalent military work experience
• 2+ years quality auditing experience, preferably in call center environment (listening to calls)
• 3+ years of work experience in an office setting environment, using the telephone and computer as the primary instruments to perform job duties
• 2+ years of experience with Microsoft Word (data entry documentation, tracking changes, create/edit docs, tables, formulas,, copy, paste, cut)
• 2+ years of experience with Microsoft Outlook (email communications and calendar)
• Intermediate to advanced knowledge of Microsoft Excel (formatting, pivot tables/charts, pareto analysis, filtering, sorting, and editing data)
• Ability to work Monday – Friday, 8am – 4:30pm EST

Preferred Qualifications:

• 2+ years claims and/or appeals and grievance experience or equivalent military work experience
• Six Sigma Experience or Certification (White Belt)
• Knowledge of healthcare coding practices (e.g., CPT’s, HCPCS, DRG, ICD-9, ICD-10)
• Healthcare industry knowledge

Telecommuting Requirements:

• Ability to keep all company sensitive documents secure (if applicable)
• Required to have a dedicated work area established that is separated from other living areas and provides information privacy.
• Must live in a location that can receive a UnitedHealth Group approved high-speed internet connection or leverage an existing high-speed internet service.

Soft Skills:

• Analytical Skills

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location, and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups, and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug – free workplace. Candidates are required to pass a drug test before beginning employment.

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