Claims Quality Auditor

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

📋 Description

• Conduct audits on transactions managed by health plan administration team members for a designated customer, which includes claims, enrollment, premium billing, paper claims, and correspondence scanning.

• Adhere to the customer quality protocols and tools for auditing and rebuttal procedures.

• Share quality assurance results with team members and collaborate with Team Leads and managers to provide constructive feedback, pinpoint errors, and highlight areas for improvement.

• Compile and present team and individual quality assurance performance metrics to management and staff.

• Contribute to Training and Team Leads regarding processing guidelines and identify needs for refresher training.

• Engage in UST HealthProof’s or clients’ Audit the Auditor initiative.

• Participate in semi-annual or annual auditor calibration sessions.

• Stay updated on CMS claims processing regulations and guidelines relevant to Medicare Advantage, ACA Exchange, and Off Exchange business lines.

• Communicate audit results to the client audit team and operational management.

⛳️ Requirements

• A High School Diploma or GED is mandatory.

• A minimum of 3 years of experience in health plan claims auditing operations is required.

• Experience in Medicaid claims auditing is preferred.

• Proficiency in MS Office Suite, specifically Excel, PowerPoint, and Outlook.

• Experience with HealthRules Payor or Guiding Care is preferred.

• Ability to analyze contractual SLAs and KPIs effectively.

• Strong communication and collaboration skills for working with a remote team.

• Candidates may need to undergo a pre-employment criminal background check.

🏝️ Benefits

• May involve travel based on company requirements.

• Reasonable accommodations will be provided for individuals with disabilities.

• Commitment to equal opportunity and workforce diversity.