Claims Quality Auditor

🔥 14 hours ago

🇺🇸 United States – Remote

💵 $44k - $58k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 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

• Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates. • Follow the customer quality process and tools for audit and rebuttal processes. • Review enrollment (834) file transactions and coordinate with state enrollment systems and enrollment brokers to confirm member effective dates, retroactive enrollment/disenrollment, and eligibility segments. • Verify timely and accurate Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards. • Audit dual-eligible Medicare-Medicaid enrollment coordination, including Medicare and Medicaid eligibility segments and coordination of benefits. • Share QA results with associates and coordinate with Team Leads and managers to provide feedback and identify errors and improvement opportunities. • Compile and report team and individual QA performance to management and associates. • Provide input to Training and Team Leads for processing instructions and refresher training needs. • Participate in the Audit the Auditor program. • Participate in semi-annual or annual auditor calibration activities. • Maintain current knowledge of CMS Medicaid managed care enrollment guidelines, state Medicaid enrollment requirements, and MLTC enrollment/disenrollment rules. • 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 required. • 3 years health plan enrollment/eligibility auditing operations experience required. • Medicaid managed care enrollment auditing experience preferred. • Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience strongly preferred. • Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook. • HealthRules® Payor or GuidingCare® experience preferred. • Familiarity with EDI 834 enrollment transactions and eligibility verification systems a plus. • Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness. • Ability to effectively communicate and collaborate with a remote team. • Candidates may be required to go through a pre-employment criminal background check.

🏖️ Benefits

• Remote work environment • May require travel dependent on company needs • Reasonable accommodations for individuals with disabilities • Equal opportunity and workforce diversity commitment

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