Quality Verification Specialist

Summary

Help protect member and provider information at Gainwell Technologies. As a  Quality Verification Specialist, you’ll conduct secondary reviews of completed verification work for member and provider account access requests and provider Electronic Funds Transfer (EFT) change requests. You’ll evaluate supporting evidence and approve, deny, or escalate requests within delegated authority. You’ll partner with compliance and account teams to resolve issues, strengthen controls, and improve processes across accounts.

This is a review-and-decision role; initial authentication, verification calls, and request processing remain with the responsible operational teams. You’ll be accountable for timely, evidence-based decisions, complete records, confidentiality, and clear communication. Senior Verification Specialists independently reassess review quality and validate corrective actions. The Director of Customer Experience (CX) Business Compliance provides compliance directions, and the CX Compliance Liaison coordinates cross-account improvements. You’ll collaborate with account leaders, Operations, Quality, Privacy, Security, and business owners.

Your role in our mission

• Review completed verification records and supporting evidence for member and provider account access requests and provider EFT change requests.
• Assess whether identity, representative authority, and required controls are adequately supported under approved account procedures.
• Evaluate submitted interactions, documentation, and verification results for completeness, consistency, and compliance.
• Confirm required authentication and information-protection controls were followed, and return incomplete or unsupported requests to submitting teams for correction.Approve, deny, or escalate requests based on documented evidence, account requirements, and delegated authority.
• Record clear decision rationale and required next steps, and confirm that separate operational, Privacy, compliance, or business-owner approvals are obtained when required.Identify discrepancies, suspected fraud, and privacy or security concerns.
• Pause affected work, preserve evidence, and follow required escalation and communication protocols.
• Communicate clear outcomes, missing-information requirements, and next steps to submitting agents through approved channels for member, provider, or representative follow-up.
• Maintain accurate, secure, and traceable case records. Preserve original evidence and audit trails and follow information-access, retention, and legal-hold requirements.

Supporting Excellence Across the Organization

• Partner with the CX Compliance Liaison, account leaders, and process owners to identify recurring issues, support root-cause analysis, and implement approved improvements across accounts.
• Report progress and barriers while respecting account-specific requirements.
• Work with Senior Verification Specialists on procedural guidance, calibration, and quality findings.
• Complete assigned corrective actions and provide supporting evidence for independent validation.
• Route independent quality reassessment and corrective-action closure validation of work in which you materially participated to another independent reviewer.
• Support onboarding, training, and knowledge sharing initiatives across the team.
• Recommend procedure and resource updates, refer policy questions and exceptions to designated compliance authorities, and perform other authorized review support and assigned duties.

What we're looking for

• High school diploma or equivalent.
• Two or more years of experience in member or provider services, provider enrollment, healthcare operations, verification, quality assurance, compliance operations, or a related field, including reviewing documentation, resolving discrepancies, or applying approval and escalation criteria.
• Ability to apply procedures, evaluate completed verification work, identify gaps, and make clear, evidence-based approval, denial, or escalation decisions within delegated authority.
• Working knowledge of confidential-information protection, fraud indicators, and escalation practices, with the ability to learn and apply account-specific identity and representative verification requirements, account access safeguards, and provider EFT controls.
• Strong attention to detail, judgment, organization, and time management to meet quality and turnaround expectations.
• Clear written and verbal communication and the ability to collaborate across compliance, quality, and account teams.
• Proficiency with Microsoft Office and SharePoint and the ability to use case-management, records, and interaction platforms.

Preferred Qualifications

• Three or more years of relevant experience, preferably in Medicaid member or provider operations, account access review, provider EFT change review, or other high-risk request decisions.
• Experience reviewing identity, representative authority, provider applications, or financial supporting documentation, including applying account access safeguards or provider EFT controls.
• Familiarity with member and provider systems, verification tools, and secure case documentation.
• Experience with quality findings, corrective actions, root-cause analysis, training, or cross-account process improvements.

What you should expect in this role

• Fully remote options from most US locations and territories

• Video cameras must be used during all interviews, as well as during the initial week of orientation
• Photo will be taken during screening for verification in all steps of the recruitment process.
• The deadline to submit applications for this posting is November 12, 2026

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Please ensure you join all screenings, interviews and meetings from a quiet location with a stable internet connection. 

Video is required for screenings and interviews, so please test your camera and microphone in advance.

Do not use AI tools, virtual backgrounds/filters, or visual enhancements during the interview.