Quality & Audit Resume Samples

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PH
P Heathcote
Providenci
Heathcote
1257 Clementina Lodge
Philadelphia
PA
+1 (555) 842 8814
1257 Clementina Lodge
Philadelphia
PA
Phone
p +1 (555) 842 8814
Experience Experience
06/2016 present
Boston, MA
Quality Audit Systems Manager
Boston, MA
Quality Audit Systems Manager
06/2016 present
Boston, MA
Quality Audit Systems Manager
06/2016 present
  • Selecting the processes to audit
  • Defining the audit protocols (what to audit, objective evidence, checklists etc.)
  • Establishing and maintain the standards for the expected outcomes from all the audits (e.g. Summary of Findings, Corrective Actions, etc.)
  • Development and deployment of continuous audit training (Internal auditors and Operations)
  • Acts as the liaison with external parties, including regulatory agencies during audits / assessments
  • Execute audits including opening and closing meetings
  • Provides advice on internal control and participates in enhancing internal audit standards and practices
08/2011 01/2016
San Francisco, CA
Quality Audit System Manager
San Francisco, CA
Quality Audit System Manager
08/2011 01/2016
San Francisco, CA
Quality Audit System Manager
08/2011 01/2016
  • Proactively work with the leadership at each site to drive continuous improvement to ensure on time delivery and quality for our Members
  • Manage Corrective Actions to closure
  • Development of metrics (CAPARs)
  • Be a business partner to Operations ensuring the Quality Control team is a leading driver in both the compliance and management of all fulfillment processes
  • Support the site Quality Team to drive the objective of 100% first pass yield, zero customer escapes, proactively supporting 100% on time delivery for the business operations
  • Provide leadership / guidance on all Internal Audit matters as well as product compliance to the facility
  • Organize and promote company-wide improvement efforts
04/2008 06/2011
Detroit, MI
Quality Audit Manager
Detroit, MI
Quality Audit Manager
04/2008 06/2011
Detroit, MI
Quality Audit Manager
04/2008 06/2011
  • Delivering Quality Audits which provide added value through continual improvement of banking services
  • Monitors and audits Process Control Forms, breakdowns and resolution. Provides review and audit
  • Provide necessary feedback in all phases of Insurance Services
  • Maintain professional ethical standards by promoting and fostering a workplace that meets Willis / Loan Protector core values
  • Leading team of Quality Audit Managers
  • Administer Quality Assurance Guidelines and Procedures for Insurance Tracking Operations
  • Delivering an internal compliance audit service incorporating audit schedule in accordance with UBS Policies and Procedures
Education Education
Bachelor’s Degree in Science
Bachelor’s Degree in Science
Howard University
Bachelor’s Degree in Science
Skills Skills
  • Intermediate Other Knowledgeable of current trends in quality improvement in managed health care
  • Intermediate Other Solid understanding of managed care and the health care industry in general
  • Intermediate Ability to lead/manage others
  • Intermediate Ability to effectively present information and respond to questions from peers and management
  • Intermediate Demonstrated ability to deal with confidential information
  • Advanced Demonstrated organizational skills
  • Advanced Demonstrated interpersonal/verbal communication skills
  • Advanced Demonstrated written communication skills
  • Intermediate Other Strong background in Quality Improvement, including planning, evaluation, quantitative analysis, and practical application of quality management principles in a managed care environment
  • Intermediate Demonstrated leadership skills
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15 Quality & Audit resume templates

1

Quality Audit Manager Resume Examples & Samples

  • Leading team of Quality Audit Managers
  • Actively managing PEX quality /projects drawing on practical experience, industry best practice and knowledge
  • Leading transformation programs
  • Designing process and products
  • Delivering an internal compliance audit service incorporating audit schedule in accordance with UBS Policies and Procedures
  • Ensuring that all Internal Compliance Audit activities are conducted objectively and in consistent manner
  • Delivering Quality Audits which provide added value through continual improvement of banking services
2

Quality Audit Claims Specialist Resume Examples & Samples

  • Experience processing both Commercial & Medicare claims
  • Minimum 2 years of medical claims processing experience in CAS
  • Beginner to intermediate experience with MS Office Excel
  • Proven ability to utilize analytical thinking in determining root cause from audit results data
  • Ability to work in a dead-line driven and production based environment
  • Strong attention to detail and accuracy
  • Experience with MTV
  • Microsoft Access experience
  • SharePoint experience
3

Quality Audit Manager Resume Examples & Samples

  • Administer Quality Assurance Guidelines and Procedures for Insurance Tracking Operations
  • Provide necessary feedback in all phases of Insurance Services
  • Ensures delivery of QA department goals and objectives
  • Monitors and reports on processes and outputs from the Escrow and Insurance Processing
  • Departments to ensure and maintain optimal operations efficiency and effectiveness
  • Ensure all procedures and policies are defect free and compliant with SLA (service level agreement)
  • Specifications
  • Monitors and audits Process Control Forms, breakdowns and resolution. Provides review and audit
  • Of the process analysis and resolution steps. Provides feedback, escalation and approval when appropriate
  • Oversees vendors by monitoring and reporting through weekly and monthly quality audits of their performance according to the agreed upon services provided to Loan Protector
  • Recruits and maintains a high performing team in support of Loan Protector’s Compliance Program and develops/trains assigned Quality Audit staff for success by providing requisite technical regulatory compliance and process training
  • Bachelors Degree in Business/Management Required
  • 5+ years experience of financial services, compliance auditing, or related experience
  • Management experience and exposure to lender placed insurance, and / or mortgage servicing preferred
  • Six Sigma Green Belt Required, Black Belt preferred
  • Exceptional planning and execution skills
  • Strong interpersonal skills required for working with all levels of management while maintaining confidentiality and utilizing discretion in sensitive situations
  • Maintain professional ethical standards by promoting and fostering a workplace that meets Willis / Loan Protector core values
  • MS Office Suite, advanced Excel skills
  • Strong and effective communication, organization, planning, and problem-solving skills
  • Ability to work as a part of a team within a fast paced environment
  • Excellent statistical and numerical ability
  • Exceptional analytical capabilities. Ability to grasp key points from complicated details
4

MRA Quality Audit Specialists Resume Examples & Samples

  • Bilingual in Spanish required
  • Bachelor’s Degree or equivalent experience required
  • Quality background desired
5

Quality Audit Manager Resume Examples & Samples

  • Bachelor’s degree in scientific, engineering or technical field with 5+ years’ experience in a medical device, biotech or pharmaceutical quality system OR Master’s degree in scientific, engineering or technical field with 3+ years’ experience in medical device, biotech or pharmaceutical quality system
  • 3+ years’ management experience in a complex environment
  • Displays and inspires enthusiasm and ownership across the organization while translating high-level business objectives into operational strategies, objectives, plans and tasks
  • Demonstrated track record of understanding and applying FDA’s Quality System Regulation and ISO 13485 requirements for quality management systems
  • Experience interacting with regulatory agencies during audits and inspections
  • Strong proficiency in Microsoft Word, PowerPoint, and Excel
  • Master’s degree in business, technical, engineering or scientific field
  • ASQ Certified Quality Auditor/Biomedical Auditor, Certified Quality Engineer, or Certified Manager of Quality/Organizational Excellence
  • High degree of analytical and critical thinking, application of good judgment and ability to communicate in writing clearly and concisely, using excellent grammar and sentence structure
  • Superior communication skills (articulate and persuasive)
  • Proven track record of achieving results through influence management and motivating teams
  • Knowledge of Medtronic and its products
  • Demonstrated knowledge of and expertise utilizing Six Sigma/Lean tools to solve complex quality system problems
6

IT Quality Audit Manager Resume Examples & Samples

  • Professional certifications should include CISA, CISSP, and/or CISM
  • At least 5-8+ years of IT Auditing experience, with “Big 4” or other recognized auditing firm preferred
  • Industry experience in the areas of IT internal audit, Security, Quality, ITIL process a plus
  • Excellent organizational, project management, written and verbal communication skills
  • Strong analytical and negotiation skills
  • Detail oriented, able to multitask and meet deadlines
  • Familiarity with IT risk assessment and audit methodologies, (i.e. COBIT)
  • Ability to interact with employees at all levels of the organization including executive management critical
  • Exposure to Archer or other risk management / automated work paper tool helpful
  • Working knowledge or exposure to Life Science industry laws and regulations in the areas of GxP, SOX, Privacy, and / or Data Integrity
7

Manager, Quality Audit Resume Examples & Samples

  • Communicates and presents quality review findings to business leaders; advises on financial impact & implications of identified risks
  • Develops & implements quality audit metrics and scorecards to analyze & assess trends as well as identify and prioritize quality issues & control gaps
  • Evaluates, develops and implements process improvements based on output of quality audits completed by his/her team
  • Executes quality control initiatives and/or solutions to identify & remediate quality issues and/or gaps in business procedures, processes, or systems
  • Leads more complex reviews & testing procedures to determine compliance with critical and required controls (e.g. company procedures, Sarbanes-Oxley, ERISA, etc.)
  • Leverages data & analysis to develop remediation plans, recommend complex solutions and/or procedural changes to reduce risk and improve business results
  • Manages a team to conduct quality audits for assigned area; facilitates participation & responsiveness from key stakeholders
  • Monitors and evaluates remediation action plan progress to ensure successful resolution of identified risk/control gaps
  • Oversees and evaluates quality assurance & control process documentation prepared by team to ensure proper documentation of testing & support conclusions
  • Partners with business leaders to develop corrective action plans; gains consensus among management to effectively implement plans to control risks & identified gaps
  • 5-7+ Years of audit or quality assurance experience directly aligned to the specific responsibilities of this role; including 2+ years of managerial, supervisory, and/or demonstrated leadership experience (Required)
  • 4 Year/Bachelors Degree or equivalent work experience (4 years of experience in lieu of Bachelors) (Minimum Required)
8

Documentation, Quality & Audit Manager Resume Examples & Samples

  • Provides leadership and direction for the unit in accordance with the overall strategic direction of the department
  • Serves as the content expert of the responsible area, providing assistance and advice
  • Communicates information effectively, translating financial data into meaningful information that support business decision-making
  • Applies understanding of operational and financial performance to anticipate and meet the needs of clients
  • Holds unit to high standards of performance
  • Assures integrity of data and analysis
  • Defines and frames complex issues and develops time tables/processes for decision making
  • Facilitates the ongoing learning, well-being
  • Kaiser Permanente conducts compensation reviews of positions on a routine basis. At any time, Kaiser Permanente reserves the right to reevaluate and change job descriptions, or to change such positions from salaried to hourly pay status. Such changes are generally implemented only after notice is given to affected employees.g, professional satisfaction and development of staff through training, work assignments, increased responsibility/autonomy and mentoring
  • Minimum seven (7) years of directly related financial experience with a variety of projects
  • 6-10 years of coding experience
9

Quality Audit System Manager Resume Examples & Samples

  • Advocate for the VOC (Voice of the Customer) ensuring customer requirements are realized throughout the life cycle of the products and processes used within the facility; from development through product realization and service support
  • Help identify, measure and in collaboration with the Operations and the Quality Control team to reduce the Cost of Poor Quality
  • Possess the ability to make decisions that always protect safety of the products and services provided by the business
  • Establish procedures for maintaining high standards of quality, reliability and safety
  • Be a business partner to Operations ensuring the Quality Control team is a leading driver in both the compliance and management of all fulfillment processes
  • Verify, track and appropriately escalate NC / CAPA issues that could impact quality or timelines
  • 10+ years of experience with Quality
  • 3+ years in a Quality Audit role
  • Customer-first mindset with the drive to understand internal and external customer expectations and requirements
  • Master's Degree
  • Aerospace, healthcare, medical device, pharmaceutical experience
  • Experience supporting Class 3 Non-Conformances; experience working with internal or external audits
10

Claims Quality Audit Rep Resume Examples & Samples

  • Performs routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory standards and timelines, business policy, contract, appropriate coding, and system configuration with ability to extract and audit exception audit reports
  • Participates in communication with Business Operations management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies and procedures
  • Identifies and escalates issues related to instructional material that is inaccurate, unclear or contains gaps. Provides recommendations for correction of this material. Confers with management to assess training needs in response to changes in policies, procedures, regulations, and technologies
  • Performs special project audits and reviews as requested by other departments/regions
  • Associate’s Degree (AA) or 2-3 years related experience and / or training; or equivalent combination of education and experience
  • 3-4 years medical claims knowledge
  • Ability to speak effectively before groups of customers or employees of the organization
  • Ability to deal with problems involving several concrete variables in standardized situations
  • Knowledge of healthcare regulations and guidelines including CMS and MHC as pertains to AB1455
  • Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms, and CPT Coding
  • Intermediate skill levels in Microsoft Word, Excel, Access, and Outlook
  • Ability to navigate internet
  • Ability to operate general office equipment, i.e. Copier, fax
11

Senior Quality Audit Rep Resume Examples & Samples

  • Lead, design, monitor, review, and evaluate the quality provided by department staff to measure service quality and identify non-conformance on all cases, to include those that are most complex, while maintaining production and time service goals. On a regular basis, provide coaching and feedback to individual staff members throughout the entire chain of our operations
  • Schedules reviews, handles appeals and/or elevated issues, and assist management with the execution of changes to our programs as needed
  • Validate accuracy of decisions/processes for adherence to set standards and/or applicable regulations or requirements. Work with internal and external parties for resolution and overall design
  • Develop, design, and prepare reports of quality results for use by management in evaluating performance or developing training
  • Personally take accountability to execute and perform standard and complex eligibility functions that are impactful throughout entire chain of our processes
  • Maintains confidentiality in the collection, maintenance and dissemination of restricted, sensitive or other information as identified by management
  • Establishes and maintains effective working relationships with personnel at all levels of the Company to assure the successful implementation and delivery of programs
  • Utilize all facets of seasoned working knowledge to recommend billing and enrollment alternatives to support the most complex and non-standard requests to establish processes and systems
  • Advanced Customer Service skills and ability to work effectively with various levels of personnel
  • Strong coaching and mentoring skills
  • Strong verbal and written communication and the ability to articulate instructions and information to other associates and customers
  • Strong analytical ability, sound judgment and math aptitude
  • Ability to work well under pressure and deadlines
  • Highly proficient with personal computer and software applications/data entry and ability to train others
  • Seasoned experience and knowledge/skills in presentation
  • Seasoned knowledge of group insurance concepts and operations
  • Thorough knowledge of all the Company's product lines
  • Thorough knowledge of applicable laws and regulations
  • Seasoned experience with Compass system and GSAP (Group Sales Application)
  • Strong knowledge of eligibility rules
12

Quality Audit Systems Manager Resume Examples & Samples

  • Provide guidance and leadership on all Internal Audit matters as well as product compliance to the facility
  • Help identify, measure and in collaboration with the Operations and the Quality Control team, reduce the Cost of Poor Quality
  • Organize and promote company-wide improvement efforts
  • Support the implementation and maintenance of the company’s Quality Management System (QMS) in accordance with current quality standards, reporting on performance of the quality system for review and as a basis for improvement
  • Support the site Quality Team to drive the objective of 100% first pass yield, zero customer escapes, proactively supporting 100% on time delivery for the business operations
  • Acts as the liaison with external parties, including regulatory agencies during audits / assessments
  • Coordinate audit schedules across all sites
  • Proactively work with the leadership at each site to drive continuous improvement to ensure on time delivery and quality for our Members
  • 10+ years of experience with Quality (Quality experience in a plant or manufacturing environment preferred)
  • Previous experience in developing and implementing an internal Quality audit program
  • Knowledge or experience with data trending, metrics generation, authoring protocols / reports
  • Knowledge with processes involved in manufacturing and distribution: QA, QC, validation, and process development
  • Capability to assimilate information and influence timely decisions that impact the functional areas
  • Knowledge and experience with Class 2 Non-Conformance
13

Quality Audit Systems Manager Resume Examples & Samples

  • Plans compliance and operational audits
  • Develops and conducts audit training
  • Conducts risk assessments and identifies controls to mitigate identified risks
  • Performs audit procedures to verify that controls are operating through testing and interviewing techniques
  • Analyzes and concludes on effectiveness and efficiency of control environment; identifies control gaps and opportunities for improvement
  • Manages scheduling of audits and through a matrixed organization - resources for audits
  • Documents the results of audit work
  • Prepares timely audit reports and conducts audit summary meetings with local and business unit management
  • Assess, evaluate and promote compliance to internal policies
  • Contributes, as appropriate with external auditors through select substantive procedures as well as process walkthroughs and testing of controls as applicable
  • Assists in internal investigations as needed
  • Provide leadership / guidance on all Internal Audit matters as well as product compliance to the facility
  • 7+ years’ of progressively more responsible work experience in any of the following functions: auditing, demonstrating the ability to execute complex audit procedures, develop corrective actions alternatives, prepare comprehensive, clear and concise audit findings and maintain objectivity and impartiality
  • 7+ years of experience with Quality
  • Proven project management skills and demonstrated experience balancing multiple tasks
  • Effective written and verbal communication skills
  • Demonstrated proficiency in Microsoft Office applications and data analysis tools
  • The ability to work well under pressure including the ability to communicate with a high degree of confidence
  • Communicates clearly, credibly, persuasively and with appropriate frequency; develops and uses personal impact to influence others to act positively
  • Builds strong working relationships both inside and outside the organization
  • Responsible for own actions and work product, follows through on commitments, produces desired results
  • Proven ability to adapt to change in direction and priority in a fast - paced, deadline - oriented environment
  • 7+ years of experience in Manufacturing
  • 7+ years of experience working in the following industries Aerospace, healthcare, medical device, and or pharmaceutical
  • Professional certification (CIA , CQA) strongly preferred
  • Ability to travel 10 - 20% desirable
  • Knowledge and experience with Class 2 Non - Conformance
14

Specialist, Quality Audit Resume Examples & Samples

  • Analyzes and evaluates trends, identifies control gaps, and recommends solutions or procedural changes
  • Collaborates with appropriate internal stakeholders (e.g. management, training, finance) to develop remediation action plans of identified risks/control gaps
  • Communicates review findings to internal stakeholders and recommends corrective action plans to control weaknesses
  • Conducts reviews and testing to determine compliance with critical and required controls (e.g. Company policy, SarbanesOxley, ERISA, etc.)
  • Develops and executes quality assurance and control review test plans including incorporating various possible methodology of achieving results, documents results and evaluates results to assess the quality of the control and/or control environment
  • Executes quality assurance and control reviews to identify and remediate quality issues and gaps in business procedures, processes or systems
  • Identifies and communicates financial implications of identified risks to management
  • Identifies internal control gaps in business procedures, processes or systems, and initiates appropriate remedial action
  • Prepares and evaluates process documentation to adequately document testing performed and to support conclusions reached
  • 1 - 3+ Years of Quality Assurance experience that directly aligns with the specific responsibilities of this position(Required)
  • 4 Year/Bachelors Degree or equivalent work experience (4 years of experience in lieu of Bachelors) in (Minimum Required)
15

Quality Audit Group Leader Resume Examples & Samples

  • Understanding of GVDP and Quality Processes
  • Proficient oral and written communication skills
  • Proficient in MS Office Applications (Word, Excel, PowerPoint)
  • Assembly plant experience (resident or support function)
16

Associate Director IT Quality Audit Resume Examples & Samples

  • 7-10 years of auditing experience in a highly regulated environment. Must demonstrate extensive knowledge of the principles, theories and concepts of computerized system auditing for compliance to GMP regulations
  • 3-5 years of experience in delivering validated IT solutions or an application support role
  • Familiarity and practical experience in the implementation of quality systems in a pharmaceutical or biotechnology manufacturing environment
  • Six-Sigma Green Belt Certification
17

Senior Specialist IT Quality Audit Resume Examples & Samples

  • Conducts computer system audits of GMP systems/operations to ensure compliance with prevailing regulatory laws and company policies through the computer system life-cycle
  • Conducts remote assessments and on-site vendor audits in support of the procurement and life-cycle monitoring of computerized system software and third party IT services
  • Responsible for the audit planning, audit execution and formal reporting of all audit results to the responsible management. Ensure responses to each audit observation is obtained and that appropriate remediation and corrective or preventive actions are taken and tracked to closure
  • Presents the results of audits to senior site and divisional management, including practical recommendations to address identified risks; requiring strong negotiation and influence skills
  • Supports the development of the GMP computerized system internal and external audit programs inclusive of procedure creation, audit tools and training delivery
  • Supports the annual development and maintenance of a risk-based audit plan/schedule including scope definition
  • Provides GMP computerized system quality and compliance consultancy and expertise to colleagues
  • Supports the analysis of quality and compliance data in order to identify and lead targeted continuous improvement efforts to improve operational process effectiveness through timely investigations and effective CAPA
  • Monitors trends, identifies compliance issues and determines opportunities for quality improvements within customer areas
  • Requests applicable resources to support audit plans
  • Is responsible for ensuring delivery of high quality and timely audit information to appropriate levels of management
  • Ensures independent and non-biased role in working with quality and compliance functional area groups to prevent any audit conflicts of interest. Collaborates with quality and compliance colleagues, as appropriate, to assure adequate focus
  • Responsible for practical knowledge of current and emerging global guidelines and regulations, relevant regulatory approaches and actions to effectively develop and advance audit strategies
  • Limited supervision required in day-to-day activities
  • Requires approximately 50 – 75% domestic and International travel for up to two weeks in duration
  • 5-7 years of auditing experience in a highly regulated environment. Must demonstrate extensive knowledge of the principles, theories and concepts of computerized system auditing for compliance to GMP regulations
  • 2-3 years of experience in delivering validated IT solutions or an application support or vendor oversight role
  • 2-3 years in a management role with proven accountability, and demonstrated excellent interpersonal, communication, negotiation, influencing, and problem-solving capabilities
  • Good understanding of a IT technology operations
  • CISA, CISP Certification and knowledge of frameworks established under COBIT and ITIL
18

Claims Quality / Audit Rep Resume Examples & Samples

  • Reviews written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers. Regarding either Professional or Institutional Claims
  • Provide expertise claims support by reviewing, researching, investigating, auditing claims
  • Analyze and identify trends and provides feedback and reports to reduce errors and improve claims processes and performance
  • Responsible for all aspects of quality assurance
  • Performs complex and extensive research, analysis and logical conclusions of paper and electronic claims to resolve disputes by providers, members and health plans
  • Conducts necessary follow-up with internal departments within set timeframes to validate payment integrity related to regulatory agencies, contracts, policy, coding, and system configuration
  • Acts as a department resource and gives support to Customer Service and researches Practice Connect issues for resolution. Responds to provider calls related to provider disputes and appeals for incoming provider/member disputes
  • Identify, trend, and report the Provider Dispute and Adjustment process for Monarch Healthcare management and prepare reports for management summarizing observations and recommendations for quality improvement
  • Provides qualified data to the Business Operations Compliance & Regulatory Manager for incorporation into training programs and policies and procedures. Confers with management to assess training needs in response to identified trends
  • Collaborates with other departments and management to implement and reinforce policy quality standards
  • Please note: This position would be in-office in either our Irvine or Long Beach, CA office locations. If a candidate is selected for Long Beach, they would need to train in our Irvine office first
  • 3+ years of experience as a Claims Examiner with previous Medicare and HMO experience
  • 3+ years of experience with dispute and resolution process (AB1455), provider appeals, Correct Coding Initiatives (CCI edits), contract language interpretation, health plan eligibility and health care benefits, or equivalent combination of education and experience
  • Intermediate skill level with Excel
  • Knowledge of Correct Coding Initiative, HCFA-1500 and UB-92 claim forms and CPT Coding
  • Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry
  • Ability to apply commonsense understanding to carry out instructions furnished in written, oral, or diagram form
  • Ability to comprehend, interpret and apply provider contract language
19

Mgr, Quality & Audit Resume Examples & Samples

  • Partners with key stakeholders across all lines of business during external and internal audits in order to provide appropriate documentation and ensure the audits are conducted in accordance with Audit Methodology and professional standards
  • Develops QA standards to monitor and improve adherence to department standards, policies and procedures, templates, formats and guidelines
  • Develops and implements studies of business function systems to include score, action plans, and analysis. Prepares narratives and graphic display of the findings
  • Communicates audit results to senior management on a regular schedule
  • Focuses on developing a systematic report quality results to help process owners root cause and prioritize their process or training opportunities
  • Direct involvement in building collaborative relationships with other departments to resolve quality issues and barriers
  • Leads and/or performs special projects, when necessary
  • Performs administration and personnel duties to include associate development, team meetings, hiring activities, etc
  • Required A Bachelor's Degree in a related field
  • Required or equivalent work experience
  • Required 3+ years of experience in relevant work as a senior, lead associate and / or supervisor - for internal applicants
  • Required 5+ years of experience in directly relevant work experience to include at least 3 years as a senior, lead associate and / or supervisor. Solid understanding of managed care and its place in the health care industry. directly relevant work experience to include at least 3 years as a senior, lead associate and / or supervisor. Solid understanding of managed care and its place in the health care industry. relevant work to include at least 3 years as a senior, lead associate and / or supervisor. Solid understanding of managed care and its place in the health care industry - for external applicants. directly relevant work experience to include at least 3 years as a senior, lead associate and / or supervisor. Solid understanding of managed care and its place in the health care industry
  • Intermediate Demonstrated leadership skills
  • Intermediate Ability to lead/manage others
  • Advanced Demonstrated written communication skills
  • Intermediate Demonstrated ability to deal with confidential information
  • Advanced Demonstrated organizational skills
  • Intermediate Ability to effectively present information and respond to questions from peers and management
  • Intermediate Other Solid understanding of managed care and the health care industry in general
  • Intermediate Other Strong background in Quality Improvement, including planning, evaluation, quantitative analysis, and practical application of quality management principles in a managed care environment
  • Intermediate Other Knowledgeable of current trends in quality improvement in managed health care
  • Intermediate Other Knowledgeable of AHCA and CMS regulatory requirements
  • Intermediate Other Knowledgeable of HEDIS and CAHPS requirements
  • Required Intermediate Microsoft PowerPoint
20

Senior Specialist Quality Audit Resume Examples & Samples

  • Ensure procedures are consistently applied as per the company's compliance standards and feedback given via reports/evaluation forms
  • Responsible for conducting one or a variety of the following audit types that range from low to high complexity
  • Guest service credit card contacts
  • Past due account contacts
  • Credit billing disputes, ensuring disputes are processed and resolved in a timely and efficient manner and within Fair Credit Reporting Act, VISA Guidelines, and Federal Regulations
  • Team Member & Retail Service contacts
  • Target internal business partner contacts; such as, stores, point of sale, headquarters, password reset, and Pharmacy
  • Transactional based processes ensuring compliance to regulatory requirements and internal policies for Target Contact Centers
  • Attends weekly discussion on policy/procedure and quality issues to ensure consistency of process
  • Surfaces trends or retraining issues to Leader
  • Use contact recording software; i.e., Witness, SmartCenter, and various contact center tools and applications
  • Ability to subjectively determine and document if best practices are being followed by Audit teams
  • Make recommendations for process improvement and participates in the implementation of new initiatives
  • Drive the different initiatives in Target India with enthusiasm and in a fast, fun and friendly way
  • Build strong partnerships across team and with TFS Mpls/Tempe in order to meet and exceed partner expectations
21

Quality & Audit Rep Resume Examples & Samples

  • Conduct quality review for all Revenue Services staff. Generally, team will review five accounts weekly for each staff member and provide feedback to leaders and staff
  • Continuously review and suggest modifications to Quality tools to enhance reviews
  • Identify system wide quality improvement trends and coordinate with the Training Specialists and Revenue Services Leaders to develop new training materials
  • Monitor Revenue Services staff to ensure quality of work is consistent with best practices
  • Apply high level of knowledge in Revenue Services to complete quality review audits as it relates to Insurance Payer/Plan Selection, Billing and Follow-up, Cash Application, Transaction Processing, Technical Denials and Variances, Customer Service, Government Cost Analytics, and/or Vendor Management
  • Strong customer service skills
  • Excellent verbal and written communication skills (ability to communicate clearly and professionally)
  • Able to work in a fast paced environment
  • An interest in continuous process and quality improvement
  • Ability to travel on a weekly basis to other ministries or sites as needed
  • Billing regulations and workflows
  • Collections strategies
  • Denials review and root cause identification
  • Reimbursement analysis based on contracts
  • Cash posting and voucher review
  • Customer Service excellence utilizing A.I.D.E.T. and executing escalation process