The Operations Auditing Coordinator II is responsible for the coordination, preparation, validation, reporting and responses of all external audits relating to complaints/grievances/appeals. This position is a valued resource in the audit process, working closely with DentaQuest’s Operations and Complaints/Grievance/Appeals teams. The Operations Audit Coordinator II will assist in identifying and recommending process improvements and policy revisions based on audit findings.
PRIMARY JOB RESPONSIBILITIES:
Manage efforts relating external audits for complaints/grievances/appeal to carry forth quality audit documentation in a timely fashion. This to include:
• Completion of audit tools provided by the auditing entity
• Compile audit universe, based on instruction received from the auditing entity
• Complete data validation of the audit universe content
• Conduct WebEx demonstrations to the auditing entity of complaints, grievances and appeals files. Accurately speak to all components of the case file content and effectively respond to any questions posed during the demonstration.
• Conduct on-site file review with the auditing entity of the complaints & grievances files
• Compile audit files, ensuring all required documentation is included. Coordinate with C&G Management to obtain documentation, as necessary.
• Conduct a thorough review of case files prior to submission for audit.
• Compile a summary of any audit findings or compliance risks identified during the internal case file review.
• Communicate all audit findings and compliance risks to the Operations Compliance Manager and to C&G Management.
• Formulate and submit rebuttal responses to audit findings in which DentaQuest disagrees with the auditing entity.
• Formulate and submit corrective action responses required by the auditing entity for any audit findings. Coordinate with C&G Management to finalize the response prior to submission.
• Communicate policy updates required as a result of audit findings.
• Communicate process changes required as a result of the audit findings.
• Cultivate and maintain professional relationships with both internal and external customers.
• Communicate effectively with both internal and external customers using various methods of communication, including email, conference call, and video conferencing.
• Demonstrate a detailed understanding of requirements for complaints, grievances and appeals, as listed in individual client contracts and in federal and/or state regulations.
• Demonstrate a detailed understanding of DentaQuest policies and processes for complaints, grievances and appeals.
• Other duties as assigned
• Proficient with general computer software including Microsoft Excel, Word and Outlook.
• Exceptional communication skills and the ability to communicate appropriately at all levels of the organization with the ability to influence others to move toward consensus. This to also include the ability to communicate appropriately with external customers, including clients and/or regulatory agencies.
• Excellent spirit for teamwork, problem-solving, communication, and decision-making skills.
• Strong situational analysis and decision making abilities.
• Excellent verbal, written, interpersonal, organizational and public speaking/communication skills. Able to effectively communicate visualizations.
• Ability to prioritize and organize multiple tasks with tight deadlines.
• Ability to manage multiple projects and priorities in a fast-paced, result-driven environment.
• Excellent independent problem solving skills
• Self-motivated and has the ability to work with little supervision and make independent decisions.
• Demonstrated track record of attention to detail.
• Bachelor’s degree in business, healthcare or related field (or equivalent work experience)
• 5+ years of experience in a related healthcare field
• Previous experience managing cases for complaints/grievance/appeals
• Previous audit experience
• Previous experience drafting policy documentation
• Ability to use basic office equipment and communicate via phone, computer technology, and via written and verbal channels.
• Ability to communicate in an active office environment, including moderate voice levels and interruptions, which may challenge hearing and concentration.
• Ability to sit for extended periods of time.
The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform this position.
** In accordance with DentaQuest’s Compliance Plan, employee must conduct DQ business in accordance with applicable laws, regulations, professional standards and ethical standards and report potential compliance or ethical issues to manager or DQ’s Compliance Officer. **
DentaQuest’s Affirmative Action Program affirms our commitment to make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please see Human Resources for additional information regarding this Program.