Claims Quality Auditor

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Gravie

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2013

🏥 Healthcare

🛡️ Insurance

🤝 B2B

💰 $150M Private Equity Round - Gravie on 2025-05

Healthcare • Insurance • B2B

Gravie is a benefits and health insurance solutions company that helps small and midsize employers, brokers, and employees access and administer more flexible, affordable health benefits. Its flagship offerings include Comfort (a level-funded health plan), Gravie ICHRA (Individual Coverage Health Reimbursement Arrangement administration), Gravie Pay (support for healthcare costs), and Gravie Care; the company focuses on enabling SMBs to offer individualized, lower-cost coverage and simplifying benefits administration.

📋 Description

• Conduct pre-payment, post-payment, and auto-adjudication audits, including routine to moderately complex claims that cover multiple benefit plan designs. • Ensure processing, payment, and financial accuracy of claims by verifying all aspects have been handled correctly according to SPDs, regulatory requirements, and standard operating procedures. • Meticulously track and report audit results, including finalized decisions for use in reporting and trending analysis. • Responsible for identifying corrections and/or adjustments needed, and to verify corrections and/or adjustments are completed and accurate. • Identify and escalate trends based on quality reviews for root cause solutioning, documentation creation and enhancement, and overall process improvement. • Investigate and research claim issues and errors to create or improve standard processing guidelines. • Participate as a SME and/or partner with system SMEs to identify and report on systemic issues which create ongoing quality concerns. • Serve on applicable cross-functional quality committees and work groups to identify and communicate common quality issues, trends, and patterns. • Support testing efforts for claims system upgrades, as needed. • Participate in client external audits. • Perform any other additional duties as necessary, including processing of claims, creating policies, and training and/or mentoring examiners through quality improvement plans. • Demonstrate commitment to our core competencies of being authentic, curious, creative, empathetic and outcome oriented.

🎯 Requirements

• Bachelor’s Degree or equivalent work experience • 2 years of experience auditing medical claims for a health insurer or TPA • Extensive (5 years) medical claims processing background • Ability to analyze data and recognize trends; use of the 5 Whys to determine the true root cause of an issue • Core system configuration knowledge • Strong independent decision-making, influencing, and analytical skills • Excellent communication skills • Demonstrated success getting results through collaboration

🏖️ Benefits

• alternative medicine coverage • flexible PTO • up to 16 weeks paid parental leave • paid holidays • a 401k program • transportation perks • education reimbursement • 2 days of paid paw-ternity leave