Role Description The ASQ Certified quality auditor ensures a company's systems, processes, and products comply with industry standards and internal regulations. He/She will evaluate the overarching processes to ensure the organization consistently delivers safe, compliant, and high-quality outcomes. - Evaluating Systems: Reviewing a company's Quality Management System (QMS) to ensure policies are properly documented and followed. - Conducting Audits: Planning, executing, and reporting on internal procedures, supplier standards, and regulatory compliance (such as ISO 9001). - Identifying Non-conformities: Pointing out areas where the organization is failing to meet established benchmarks or protocols. - Recommending Improvements: Analyzing root causes of inconsistencies and suggesting actionable corrective actions. - Stakeholder Communication: Presenting findings clearly to management and ensuring all corrective measures are properly implemented and verified. Qualifications - Certification as a Quality Auditor (CQA) - Minimum of 3 years of experience in a quality control role - Excellent attention to detail and problem-solving skills - Excellent communication and interpersonal skills - Ability to work independently and as part of a team - Familiarity with ISO 9001, or similar quality management standards - Experience with government contract is preferred.

• Under supervision, investigates claims liability and determines the extent of liability on submitted claims for an overall contract that is approaching or exceeds the aggregate attachment point • Accurately processes the claim according to the policies or contracts that exist, within the departmental time frames and standards, and establishes reserves for claim liability • Review and interpret employer plans of health coverage and excess insurance policy • Audit monthly and year-end aggregate claims for payment from receipt through completion • Follow-up on missing documentation when necessary • Interpret paid claims reports, eligibility reports, funding documentation, check registers, prescription reports to verify contract/plan document is being followed correctly • Communicates in writing and verbally with third-party administrator (TPA)/client as needed to resolve claim processing issues • Set claims reserves and adjusts as needed • Keep the reserves current • Interpret contract/plan document and determine appropriate reimbursement • Also determine any out-of-contract items/amounts • Obtain refunds from TPA when year-end results indicate monthly accommodations were too large • Maintain quality, quantity, and turnaround time standards of company • Review the TPA/client operations to verify in guidelines of contract/plan documents

Role Description This role is part of the training team for the Clinical Chart Validation team. This position is responsible for improving the technical effectiveness of our teams by planning, developing, and delivering technical training, mentoring, and assessment. The individual will work collaboratively with subject matter experts in the Commercial & Government Audit Teams, Quality Assurance, Concept Development, and others to validate workflows and communication tools to enhance audit productivity, performance, and client satisfaction. Responsibilities - Training, Development, and Mentoring: - Assess job-specific needs and develop technical training plans with clear business objectives. - Select training/instructional methods and procedures appropriate for the situation. - Deliver specific training sessions using suitable delivery methods such as classroom, online, and webinar. - Identify the development needs of others and coach, mentor, or assist others with improving their knowledge skills. - Provide support to the CCV audit team members; assist with orientation of new members as needed. - Promote audit accuracy measures by training/educating and mentoring the auditor. - Encourage critical thinking and discussion among team members on concepts as needed. - Provide training on one or more of the following audit types: Place of Service & Readmission. - Confer with management and conduct surveys to identify training needs. - Participate in weekly/monthly team meetings to share best practices initiatives. - Support the Medical Director to ensure accurate assessments of improper payments. - Assess customer/provider/stakeholder issues, complaints, and compliments. - Monitor/Assess the performance of self, other individuals, &/or organizations. - Work with the Quality Team to train audit team members on findings from quality review audits. - Develop testing and evaluation procedures. - Evaluate instructor performance and the effectiveness of training programs. - Conduct or arrange for ongoing technical training and personal development classes for staff members. - Quality Assurance Controls: - Integrate healthcare auditing principles and use objectivity in the performance of medical audit activities. - Draw on healthcare proficiency and industry knowledge to substantiate conclusions. - Perform work independently, review and interpret audit work of others. - Review medical records and apply in-depth knowledge of clinical criteria. - Demonstrate an understanding of complex contract specifications. - Provide feedback on reviews to the Quality Assurance Manager. - New Concepts and Processes: - Develop reasonable and effective recommendations for concept solutions. - Suggest and/or develop and implement new ideas, approaches, and technological improvements. - Collaborate with Data Services in developing new reports. - Meets or Exceeds Standards/Guidelines for Productivity: - Maintain production goals and quality standards set by the audit. - Perform QA audits against the expected level of quality and quantity. Qualifications - Education/Certification/Licenses (required): - Associate or Bachelor's degree in nursing. - RN License (active/unrestricted in state of residence). - Case Management Certification (preferred, but not required). - Additional certifications in Interqual or MCG (preferred, but not required). - Experience: - 5 to 7+ years of working with InterQual/MCG (Inpatient vs Observation). - Background in Utilization Management and/or Case Management. - Critical Care background: ICU, Emergency Room, Cath Lab, Med Surg. - 5 to 7+ years of working with a broad knowledge of medical claims, billing/payment systems. - Adherence to official coding guidelines and other regulatory compliance guidelines. - Strong presentation skills. - Independent thinker, logical, strategic, with a high focus and attention to detail. - Effective communication and presentation style (written and verbal). - Knowledge of principles and methods for curriculum and training design. - Competent administrative and organizational skills. - Professional demeanor with problem-solving abilities. - High level of proficiency with all audit technology (i.e., R3, CAT, etc.). - Proficiency in Word, Access, Excel, PowerPoint, and other applications. - Excellent written and verbal communication skills. - Applicants should have home health, IRF, and SNF experience. Requirements - Mental Requirements: - Communicating with others to exchange information. - Problem-solving and thinking critically. - Completing tasks independently. - Physical Requirements and Working Conditions: - Remaining in a stationary position, often standing or sitting for prolonged periods. - Repeating motions that may include the wrists, hands, and/or fingers. - Must be able to provide a dedicated, secure work area. - Must be able to provide high-speed internet access/connectivity and office setup. - No adverse environmental conditions are expected. Benefits - Base compensation ranges from $105,000 to $125,000 per year. - Eligible for discretionary bonus consideration. - Competitive benefits package including: - Medical, dental, vision, disability, and life insurance coverage. - 401(k) savings plans. - Paid family leave. - 9 paid holidays per year. - 17-27 days of Paid Time Off (PTO) per year.

• Maintain a comprehensive and topical understanding of the prevailing PIPAG and Clinical Guidance Notes emanating from the Clinical Governance Team, pro-actively seeking clarity if required. • Quality check a specified volume of reports per day against the criteria determined and communicated by the in-house Clinical Governance Team based on their interpretation of the most topical PIPAG. • Provide, if necessary, constructive and impartial advice in the form of audit feedback to FS to enable them to amend and subsequently re-submit fit-for-purpose reports. • As part of the audit feedback process to recognise strengths in the written reports making specific reference in the feedback. • Provide constructive, impartial and supportive advice to FSs who contact the telephone support lines ensuring that the content of the conversation is, on every occasion accurately recorded in the appropriate section of CRM so FSQ colleagues can reference the interaction as part of any subsequent auditing which may be undertaken on the case discussed. • As part of their Quality, Learning and Support process to alert the FSQTM where an emotional or clinical support requirement has been identified for a FS. • Ensure continuous full compliance with Capita Group and Local Online Mandatory Training (OMT) and Continuous Professional Development (CPD) modules. – abiding to Capita’s policies and procedures. • Maintain professional registration and Authority Approval and to act in accordance with the relevant UK Professional Code of Conduct, being accountable for your own practice and professional actions at all times. • Contribute to clinical and service transformation including piloting new initiatives. • Undertake any other duties, as required by the Business commensurate with the role. • Be clinically calibrated to the standards set by the CMO and Clinical Governance Mgt. Team.