Claims Quality Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Ensure the precise and accurate processing of medical claims in accordance with contractual obligations and regulatory standards.

• Execute pre-payment, post-payment, and auto-adjudication audits for claims.

• Guarantee the accuracy of processing, payment, and financial aspects of claims.

• Diligently track and report audit findings.

• Identify necessary corrections and validate the accuracy of adjustments.

• Highlight trends and issues for potential process enhancements.

• Investigate claim-related issues to refine standard processing protocols.

• Engage in cross-functional quality committees.

• Assist in testing initiatives for claims system upgrades.

• Take part in external audits conducted by clients.

• Process claims and develop policies as required.

⛳️ Requirements

• Bachelor’s Degree or equivalent professional experience.

• A minimum of 2 years of experience auditing medical claims for a health insurer or Third-Party Administrator (TPA).

• Extensive background (5 years) in medical claims processing.

• Proficiency in data analysis and trend recognition; application of the 5 Whys technique to determine the underlying cause of issues.

• Knowledge of core system configuration.

• Ability to convey findings clearly and defend the methodologies employed to produce those findings.

• Strong skills in independent decision-making, influencing, and analysis.

• Exceptional communication abilities.

• Proven success in achieving results through collaboration.

• Experience in a startup environment (extra credit).

• Background in Payment Integrity (extra credit).

• Coding certification from AAPC or AHIMA (extra credit).

• Familiarity with Javelina claims processing software (extra credit).

🏝️ Benefits

• Coverage for alternative medicine.

• Generous Paid Time Off (PTO).

• Up to 16 weeks of paid parental leave.

• Paid holidays.

• 401k retirement plan.

• Transportation benefits.

• Education reimbursement.

• Paid paw-ternity leave.