Provider Network Quality Assurance Specialist

Accountabilities: Develop and maintain a structured audit schedule for provider network operations, ensuring reviews are completed consistently and documented appropriately. Conduct research, analyze operational data, and recommend improvements to address administrative, organizational, and process-related issues. Maintain complete audit evidence and records to support internal reviews, external audits, regulatory assessments, and accreditation requirements. Evaluate provider directory accuracy and document review findings and follow-up activities in accordance with applicable DHB and NCQA requirements. Compare published provider directory information with source systems, coordinating provider outreach and internal research to resolve unverified, incomplete, or conflicting details. Prioritize corrections that could affect member access to care, directory search results, or regulatory compliance. Review provider records across Salesforce, the Alliance Claims System (ACS), enrollment documentation, and contracting systems to identify trends, inconsistencies, and data quality issues. Verify that contract terms, effective dates, network participation, service locations, and reimbursement attributes are accurately recorded. Compare system records against applications, signed contracts, enrollment requests, and approved change requests to identify missing, expired, duplicated, or incorrectly entered information. Route identified discrepancies to the appropriate teams, monitor progress, and track corrections through resolution. Maintain current audit criteria that reflect applicable DHB, NCQA, state, contractual, regulatory, and internal policy requirements. Document compliance gaps, evaluate potential risks, and promptly escalate significant findings to the appropriate stakeholders. Support regulatory and accreditation reviews by gathering requested information, preparing documentation, and responding to internal and external information requests. Conduct root cause analyses to identify recurring errors, determine contributing factors, and recommend sustainable solutions. Partner with responsible teams to establish corrective and preventive action plans, including assigned owners, milestones, and deadlines, and maintain documentation of analyses and outcomes. Promote cross-functional collaboration and continuous improvement across provider network operations. Requirements Bachelor's degree from an accredited college or university in Human Services, Sociology, Psychology, Public Health, Statistics, Economics, Business Administration, or a related social science field. At least five years of relevant experience performing quality assurance or quality improvement activities. Demonstrated experience leading project teams focused on quality improvement initiatives. Advanced proficiency in Microsoft Office applications, particularly Excel, including the ability to analyze data and create clear graphs and tables. Strong analytical and problem-solving skills, with the ability to identify data discrepancies, recognize trends, conduct root cause analyses, and develop practical recommendations. Excellent written and verbal communication skills, including the ability to prepare clear audit documentation, summarize findings, and communicate corrective actions. Strong organizational and time management skills, with the ability to manage multiple projects, prioritize competing deadlines, and maintain accurate records. Experience with MicroStrategy or other statistical analysis, reporting, or data modeling tools is preferred. Experience developing quality improvement plans for services supporting individuals with complex needs, including physical health, behavioral health, and social determinants of health, is an advantage. Familiarity with project management methodologies and processes is desirable. Prior experience in managed care is preferred. Ability to work effectively with members, network providers, families, government personnel, and internal stakeholders in a respectful, compassionate, and culturally responsive manner. Flexibility, adaptability, and a willingness to learn new systems, processes, and skills. Must reside in North Carolina to meet the position's remote-work requirements and be available for occasional onsite meetings in Morrisville, North Carolina. Benefits Annual salary range: $69,592–$88,729, with final compensation determined by education, experience, external market data, and internal equity. Healthcare coverage: Medical, dental, and vision insurance. Additional protection: Life insurance and long-term disability coverage. Retirement: A comprehensive retirement savings plan. Work flexibility: Flexible work schedules, including remote and hybrid options, subject to role requirements. Paid time off: Vacation, sick leave, holidays, and management leave. Dress flexibility: A flexible dress policy. Employment type: Full-time position. Work arrangement: Remote within North Carolina, with occasional travel to the Morrisville office as required.