Quality Configuration Audit Senior

Anticipated End Date:

2025-07-04

Position Title:

Quality Configuration Audit Senior

Job Description:

JR142986 Quality Configuration Audit Senior

Hybrid 1: This role requires associates to be in-office 1-2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

Carelon Health is a proud member of the Elevance Health family of brands, offering clinical programs and primary care options for seniors. We are a team of committed clinicians and business leaders passionate about transforming American healthcare delivery.

The Quality Configuration Audit Senior will be responsible for driving service quality excellence by evaluating the quality of services and interactions provided by organizations within the enterprise.  Included are processes related to provider and pricing configuration and respective downstream processes, as will as provider inquires.

How you will make an impact:

• Acts as auditor in charge for audits and special projects, producing engagement planning and testing strategies.
• Translates business need into appropriate, comprehensive quality validation strategies and design.
• Participates in pre and post implementation audits of provider configuration, claims processing and payment, benefit coding, member and provider inquiries, enrollment & billing transactions and the corrective action plan process.
• Audits multiple lines of business, multiple functions, and multiple systems.
• Trend audit results and perform data analysis on trends to determine/recommend adjustments to quality reviews.
• Work closely with the business to provide consultation and advice to management related to policy and procedure identified as out of date or incomplete and investigates, develops and recommends process improvements and solutions.
• Manage process improvement process; May include activities such leading workgroups, facilitating SWAT sessions, drafting new workflow or procedures.
• Functions as a subject matter expert for discrepancy review, questions from team and business partners, and interpretation of guidelines and audit process.
• Facilitate and lead meetings with business to review audit plan, audit findings and/or recommendations for improvement.
• Acts as a mentor to peer auditors, providing training and managing work and projects as necessary.
• Facilitate calibration sessions with the business area, support areas, vendors or clients.

Minimum Requirements:

• Requires a BS/BA; 4-5+ years related experience in provider or pricing configuration or any combination of education and experience, which would provide an equivalent background. 

Preferred Skills, Capabilities and Experiences:

• Nursing Degree strongly preferred.
• Clinically relevant certification (i.e. Certified Diabetes Educator, Certified Case Manager) and a background in quality or performance improvement preferred.
• Experience with medical coding and medical terminology preferred.

Job Level:

Non-Management Exempt

Workshift:

1st Shift (United States of America)

Job Family:

QLT > Audit

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock pu