Claims Quality Audit Lead

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $55k - $70k / year

⏰ Full Time

🟠 Senior

🦅 H1B Visa Sponsor

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👻 Ghost score 0%

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HealthEdge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2005

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

HealthEdge is a company that specializes in providing advanced solutions for healthcare payers through its HealthRules Solutions Suite. This suite includes a comprehensive digital claims administration processing system, care management workflow solutions, and payment integrity solutions, which aim to enhance operational efficiency and improve quality of care for health plans. By leveraging integrated technology and automation, HealthEdge helps health plans eliminate data silos, increase payment accuracy, and elevate member experience, thereby transforming the healthcare landscape for better collaboration and accessibility.

📋 Description

• Facilitate and lead client calibration calls to align scoring standards and expectations • Partner with internal stakeholders to maintain consistent quality scoring practices • Monitor analyst productivity and ensure 8–10 monthly scorecards per analyst are completed and accurately tracked • Maintain scorecard completion compliance and escalate productivity or coverage issues • Conduct side-by-side reviews and calibrations with analysts • Deliver targeted coaching to reinforce accuracy, consistency, and development • Perform “quality on quality” reviews to validate analyst scoring and reporting integrity • Prioritize speech analytics initiatives until Cresta is fully implemented across all clients • Identify trends and systemic issues through quality reviews and propose solutions to leadership • Partner with training and operations teams to close agent-performance gaps and improve member experience • Develop, refine, and maintain the quality program • Facilitate peer calibration sessions across team, client, and agent groups • Work with leadership and trainers to identify training opportunities

🎯 Requirements

• 3+ years in quality assurance, performance management, or a related call center/business operations environment • Strong analytical skills with ability to interpret data and identify actionable trends • Proficiency in MS Excel, reporting tools, and quality monitoring platforms • Experience in calibration sessions with clients and/or internal stakeholders • Strong organizational and time management skills • Bachelor’s degree in business, Operations, Quality Management, or related field (or equivalent experience) • Ability to analyze call center data, report KPIs and operations reports, and present findings in a structured way • Ability to convey messages with understanding to multiple organizational levels • Attention to detail and accuracy • Results-driven mindset • Excellent analytical, organizational, problem-solving, verbal, and written communication skills • Ability to work independently and within a team environment while managing multiple priorities and deadlines • Ability to contribute to cross-functional, complex process improvement projects and lead limited-scope process improvement initiatives within the Enrollment team • Proficient in industry-standard PC applications and systems, including Access, Excel, Word, and PowerPoint • May be required to complete a pre-employment criminal background check

🏖️ Benefits

• Remote work environment • Hybrid or remote work environment across multiple time zones • Potential travel dependent on company needs • Reasonable accommodations for individuals with disabilities • Equal opportunity and workforce diversity commitment