Senior Verification Specialist

Protect member and provider information through independent, second-level quality reviews using an “audit-the-auditor” approach. As a Senior Verification Specialist, you’ll reassess completed verification reviews and independently retest underlying evidence, controls, decisions, and handoffs—from intake and authentication through verification, approval, processing, communication, escalation, and closure. Your scope includes assessing member and provider interactions related to member and provider account access requests, including portal administrator access changes, and provider Electronic Funds Transfer (EFT) change requests. You’ll report findings, communicate results, and partner with account leaders to drive people, process, and technology improvements, validate corrective actions, and guide Verification Specialists while maintaining review independence.

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.

Your role in our mission

Serve as an independent line of defense by evaluating verification activities, identifying risks, and ensuring compliance with established policies, procedures, and controls. Your work helps protect member and provider information, strengthen operational integrity, and support regulatory compliance.

• 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.

Supporting Excellence Across the Organization

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.

What we're looking for

• Five or more years of experience in member services, member or provider verification, provider enrollment, healthcare operations, compliance operations, or a related field, including quality reviews or operational control testing across multi-step workflows.
• Ability to apply policies and procedures, independently reassess completed verification reviews, retest underlying controls and handoffs across the account access and provider EFT change-request lifecycle, reconcile conflicting information, and document objective, evidence-based conclusions.
• Working knowledge of member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and cross-team handoffs.
• Strong analytical, organizational, and time-management skills to prioritize high-risk work and meet quality and turnaround requirements.
• Clear written and verbal communication; ability to prepare findings reports, present results and risk-based recommendations to leadership and operational teams, guide and coach Verification Specialists, promote consistent review standards, and partner on people, process, and technology improvements.
• Proficiency with Microsoft Office and SharePoint; ability to use case-management systems, approved records repositories, and interaction-recording or quality-review platforms.

Preferred Qualifications

• Experience in Medicaid member services or provider operations, quality reviews of member and provider interactions related to account access and provider EFT change requests, or end-to-end reviews of EFT, portal administrator access, or other high-risk provider changes.
• Experience with independent second-level quality reviews, risk-based sampling across roles and process stages, finding classification, root-cause analysis, corrective-action validation, cross-functional trend reporting, and recommendations for people, process, or technology improvements.
• Familiarity with CXone or comparable interaction-review platforms, member and provider systems of record, and business-verification tools.

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

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.

The pay range for this position is $63,000.00 - $90,000.00 per year, however, the base pay offered