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.