Provider Network Quality Assurance Specialist

We are seeking a detail-oriented Provider Network Quality Assurance Specialist to strengthen the accuracy, integrity, and compliance of provider network operations. This full-time remote role combines data analysis, documentation, project coordination, and continuous improvement in a healthcare environment. Candidates must reside in North Carolina and be willing to travel occasionally to the Morrisville, NC, office for onsite meetings.

• Develop and maintain a structured audit schedule for provider network operations.
• Conduct research, analyze operational data, and recommend improvements.
• 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.
• 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.
• 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.
• 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.
• Support regulatory and accreditation reviews by gathering requested information, preparing documentation, and responding to 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.
• Promote cross-functional collaboration and continuous improvement across provider network operations.

• 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.
• Strong analytical and problem-solving skills.
• Excellent written and verbal communication skills.
• Strong organizational and time management skills.
• 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 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.
• Flexibility, adaptability, and a willingness to learn new systems, processes, and skills.
• Must reside in North Carolina and be available for occasional onsite meetings in Morrisville, North Carolina.

• 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.