Senior Quality Verification Specialist

You will be responsible for conducting independent quality and compliance reviews of member and provider interactions involving account access requests and provider EFT change requests. This role ensures requests are handled accurately, securely, and in accordance with established procedures, confidentiality requirements, and conflict-of-interest standards.

Working closely with Compliance, Operations, Quality, Privacy, Security, and other authorized stakeholders, the reviewer evaluates end-to-end request processing, documents findings, validates corrective actions, and confirms sustained process improvements. The position serves as an objective quality resource, providing clear reporting, risk identification, and compliance guidance while maintaining independence from operational decision-making. Reviews must be completed within delegated authority, and any case in which the reviewer had direct involvement must be reassigned to another independent reviewer for evaluation and closure validation.

• Independently reassess completed reviews using an "audit-the-auditor" approach to evaluate the completeness, accuracy, consistency, and appropriateness of prior verification reviews, findings, decisions, and escalations. Apply random, risk-based, targeted, and retrospective review methodologies while retesting controls, documentation, decisions, and handoffs against requirements in effect at the time of processing.
• Retest verification controls to confirm completed verification activities support identity, representative authority, affiliation, and ownership requirements. Validate authentication procedures, protection of verification responses, and adherence to required call controls, scripts, disclosures, and documentation standards.
• Assess member and provider interactions related to account access requests and provider EFT changes, ensuring information accuracy, professional communication, proper authorized representative handling, complete documentation, and compliance with escalation and follow-up requirements.
• Test high-risk request controls by evaluating request completeness, supporting evidence, signatures, organizational relationships, email and website validations, banking information verification, ownership verification, authorized exceptions, and portal access administration activities.
• Report findings and communicate results through clear, evidence-based reporting. Document review scope, sampling methods, findings, risks, severity, rationale, and recommendations, while presenting results to compliance leadership, business leaders, and process owners.
• Escalate critical risks immediately, including suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and other significant compliance issues in accordance with established escalation procedures.
• Validate corrective actions by tracking remediation efforts, supporting root-cause analysis, confirming effectiveness of corrective measures, and escalating overdue or ineffective actions.

Leverage audit and quality findings to improve processes, strengthen controls, and support organizational performance through collaboration, coaching, and continuous improvement initiatives.

• Preserve review evidence by maintaining complete, traceable records tied to original case documentation while adhering to retention, access, and legal hold requirements.
• Drive people, process, and technology improvements by translating trends and findings into actionable recommendations for training, procedures, workflows, system enhancements, automation opportunities, and control improvements.
• Guide and develop colleagues by providing evidence-based coaching, supporting onboarding and knowledge sharing, identifying training needs, and recommending updates to procedures, scripts, checklists, and reference materials.
• Support authorized operational work through approved verification activities, member and provider follow-up, and operational support responsibilities while maintaining appropriate separation from reviews of the same cases.
• Maintain independent review practices by ensuring objectivity, avoiding conflicts of interest, and routing cases you performed or materially influenced to an independent reviewer for reassessment or closure validation.