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Healthfirst QA Financial Auditor I in Home Office, Montana

The Quality Assurance Financial Auditor is responsible for performing Quality Assurance Audits of financial processes completed by internal employees and outsourced vendors to ensure compliance with policies, procedures, and quality standards to mitigate financial risk. The incumbent investigates, audits, conducts root cause analysis, handles processing of determinations, and tracks/trends findings under minimal supervision.

  • Conduct routine and moderately complex quality audits of provider claims, pre-payments, and post-payments utilizing appropriate sources of information including eligibility, enrollment, state contracts, provider and facility contracts, and state and health plan billing manuals

  • Identify trends, issues, and exceptions and provide feedback to appropriate leaders of financial-related work such as claims, electronic fund transfer (EFT), member billing, accounts receivable, etc.

  • Confirm employee adherence to company, state and federal policies and procedures including compliance and regulatory guidelines

  • Analyze errors and determine root causes for appropriate classification

  • Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure the quality of the network

  • Review and investigate claims and encounters for medical, facility, pharmacy, dental and vision services including contractual provisions, authorizations and Healthfirst policy and procedure

  • Prepare written reports concerning investigation activities and present results of investigations to senior staff

  • Complete subsequent auditing and handling of specific claim and appeal requests including processing (where applicable), tracking, documenting, reporting and dispersal of findings and recommendations

  • Identify quality, operational efficiency, and production goal defects to support the improvement of departmental performance

  • Identify patterns, trends and variances related to audited performance

  • Assist in the development of departmental policies and procedures

  • Review the accuracy and efficiency of existing training materials

  • Meet established time frames and rates of performance for both quality and quantity of work

  • Comply with HIPAA guidelines and maintain confidentiality of employee, member, provider, medical and departmental information

Minimum Qualifications:

  • Audit experience including investigation, determination, and reporting

  • Work experience in Microsoft Office suite of applications including Excel (which includes formatting formulas, managing data, and filtering results), Word, PowerPoint, and Outlook

  • Experience conducting analytical work and providing creative ideas for problem solving

  • Work experience requiring written and verbal communication that is clear, concise, grammatically correct, and professional

  • High School Diploma or GED from an accredited institution

    Preferred Qualifications:

  • Associate degree or higher

  • Auditing of financial processes

  • Experience handling Personal Health Information (PHI) in a professional manner

  • Ability and willingness to handle increasing workload and responsibility

  • Willingness and ability to learn and evaluate new information, both technical and procedural

  • ICD10 certification

  • Experience in an Auditing capacity where you have conducted root cause analysis

  • Knowledge of at least two or more lines of business such as NY Medicare, Medicaid, Family Health Plus, Child Health Plus, etc.

Compliance & Regulatory Responsibilities: See Above

License/Certification: N/A

Since we care so greatly about our employees' and members' wellbeing, Healthfirst has implemented various COVID-related health and safety requirements for our workforce. Employees are expected to follow the Company’s current COVID-19 or other infectious disease health and safety protocols, including local requirements, which may include sharing information regarding your vaccine status and mask wearing. Protocols may change in the future with the evolving public health landscape. Healthfirst will consider accommodation requests as required by applicable law.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement (

All hiring and recruitment at Healthfirst is transacted with a valid “” email address only or from a recruitment firm representing our Company. Any recruitment firm representing Healthfirst will readily provide you with the name and contact information of the recruiting professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by Healthfirst. Healthfirst will never ask you for money during the recruitment or onboarding process.

Hiring Range*:

  • Greater New York City Area (NY, NJ, CT residents): $56,000 - $74,880

  • All Other Locations (within approved locations): $48,600 - $70,720

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.