Membership Quality Auditor - San Antonio, TX

Careers at UnitedHealth Group

We're creating opportunities in every corner of the health care marketplace to improve lives while we're building careers. At UnitedHealth Group, we support you with the latest tools, advanced training and the combined strength of high caliber co-workers who share your passion, your energy and your commitment to quality. Join us and start doing your life's best work. SM


Compassion. It's the starting point for health care providers like you and it's what drives us every day as we put our exceptional skills together with a real feeling of caring for others. This is a place where your impact goes beyond providing care one patient at a time. Because here, every day, you're also providing leadership and contributing in ways that can affect millions for years to come. Ready for a new path? Learn more, and start doing your life's best work. SM

Our teams are helping people from around the world. We can bring out your best as you put your listening, analytical and problem solving skills to work in a setting that is geared to helping improve lives and enhance health care for millions. Here, you'll discover a wealth of pathways for professional growth within Customer Service, Billing, Claims, Enrollment & Eligibility and across our global economy. Join us and find out why this is the place to do your life's best work. SM

Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life's best work.(sm)

The Membership Quality Auditor reviews and audits the end-to-end EDI load process for accuracy and appropriateness in regard to membership eligibility, PCP assignment and handling of exceptions. Additionally, reviews and audits will be performed on the maintenance of membership records and eligibility inquiries. This position will also assist in the development of various tools that improve business processes as well as provide guidance to all Eligibility and Systems Specialists.

Primary Responsibilities:
  • Assist with creation and maintenance of business process documentation, including flow charts and decision trees
  • Review and provide results from EDI load process to ensure all business processes for exceptions were followed accordingly
  • Review and audit operational reports to ensure accurate maintenance of all member records.
  • Review responses to eligibility inquiries for accuracy and timely handling
  • Participate in the development of systems that automate the identification of membership or eligibility errors and tracks errors and resolutions
  • Assist in the development of tools to facilitate the sharing of information and feedback with customers
  • Participate in projects associated with compliance audits and focus audits
  • Assist with creation and maintenance of business process documentation, including flow charts and decision trees
  • Analyze data and report results during audit initiatives
  • Understands, interprets and applies business policies and procedures that impact membership and eligibility accuracy
  • Maintains current knowledge of CMS/Medicare Advantage regulations in support of audit initiatives
  • Performs all other related duties as assigned

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 or GED
  • 2+ years of experience in managed care eligibility
  • 1+ years of experience in a Quality Assurance role
  • Excellent Excel skills with the ability to create pivot tables for the purpose of analysis

Preferred Qualifications:
  • Bachelor's degree in Business, Healthcare or related field
  • 2+ years of experience with EDI processing
  • Experience as a business or technical writer
  • Experience with the IKA Claims system
  • Exceptional ability to organize, prioritize and communicate effectively
  • Utilizes experience and judgment to plan, accomplish goals and effectively solve problems
  • Ability to make decisions based on sound knowledge
  • Performs a variety of tasks that may require a limited degree of creativity and latitude
  • Full COVID-19 vaccination is an essential requirement of this role. UnitedHealth Group will adhere to all federal, state and local regulations as well as all client requirements and will obtain necessary proof of vaccination prior to employment to ensure compliance

To protect the health and safety of our workforce, patients and communities we serve, UnitedHealth Group and its affiliate companies now require all employees to disclose COVID-19 vaccination status prior to beginning employment. In addition, some roles require full COVID-19 vaccination as an essential job function. UnitedHealth Group adheres to all federal, state and local COVID-19 vaccination regulations as well as all client COVID-19 vaccination requirements and will obtain the necessary information from candidates prior to employment to ensure compliance. Candidates must be able to perform all essential job functions with or without reasonable accommodation. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.

Careers with WellMed. Our focus is simple. We're innovators in preventative health care, striving to change the face of health care for seniors. We're impacting 550,000+ lives, primarily Medicare eligible seniors in Texas and Florida, through primary and multi-specialty clinics, and contracted medical management services. We've joined Optum, part of the UnitedHealth Group family of companies, and our mission is to help the sick become well and to help patients understand and control their health in a lifelong effort at wellness. Our providers and staff are selected for their dedication and focus on preventative, proactive care. For you, that means one incredible team and a singular opportunity to do your life's best work.(sm)

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.

Job Keywords: Membership Quality Auditor, Managed Care, Eligibility, Quality Assurance, San Antonio, TX, Texas