Claims Quality Auditor

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

📋 Description

• Conduct audits on enrollment, disenrollment, eligibility, and plan/PCP change transactions handled by health plan enrollment associates.

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

• Review enrollment (834) file transactions and collaborate with state enrollment systems and enrollment brokers to verify member effective dates, retroactive enrollment/disenrollment, and eligibility segments.

• Ensure timely and accurate Medicaid eligibility redeterminations and recertifications in compliance with CMS and state Medicaid timeliness standards.

• Audit coordination for dual-eligible Medicare-Medicaid enrollment, including Medicare and Medicaid eligibility segments and benefits coordination.

• Share quality assurance results with associates and work with Team Leads and managers to provide feedback and identify errors and areas for improvement.

• Compile and communicate team and individual quality assurance performance to management and associates.

• Contribute input to Training and Team Leads regarding processing instructions and refresher training requirements.

• Engage in the Audit the Auditor program.

• Take part in semi-annual or annual auditor calibration activities.

• Stay updated on CMS Medicaid managed care enrollment guidelines, state Medicaid enrollment regulations, and MLTC enrollment/disenrollment procedures.

• Report to the Lead Auditor or Quality Audit Manager and interact daily with client audit teams and operational managers.

⛳️ Requirements

• High School Diploma or GED is required.

• Minimum of 3 years of experience in health plan enrollment/eligibility auditing operations is required.

• Experience in Medicaid managed care enrollment auditing is preferred.

• Strong preference for candidates with managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience.

• Proficiency in MS Suite, particularly Excel, PowerPoint, and Outlook.

• Preferred experience with HealthRules® Payor or GuidingCare®.

• Familiarity with EDI 834 enrollment transactions and eligibility verification systems is a plus.

• Capability to analyze contractual SLAs and KPIs, especially regarding enrollment processing timeliness.

• Strong ability to communicate and collaborate effectively with a remote team.

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

🏝️ Benefits

• Remote work environment.

• Travel may be required based on company needs.

• Reasonable accommodations for individuals with disabilities.

• Commitment to equal opportunity and workforce diversity.