Claims Quality Auditor

🔥 14 hours ago

🇺🇸 United States – Remote

💵 $44k - $50k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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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 transactions processed by health plan administration associates for a specific customer, including claims, enrollment, premium billing, paper claims, and correspondence scanning. • Follow the customer quality process and tools for audit and rebuttal processes. • Share QA results with associates and coordinate with Team Leads and managers to provide feedback, identify errors, and highlight improvement opportunities. • Compile and report team and individual QA performance to management and associates. • Provide inputs to Training and Team Leads for processing instructions and refresher training needs. • Participate in UST HealthProof’s or customers’ Audit the Auditor program. • Participate in semi-annual or annual auditor calibration activities. • Maintain current knowledge of CMS claims processing rules and guidelines for Medicare Advantage, ACA Exchange, and Off Exchange lines of business. • Report audit findings to the client audit team and operational managers.

🎯 Requirements

• High School Diploma or GED required. • 3 years health plan claims auditing operations experience required • Medicaid claims auditing experience preferred. • Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook • HealthRules Payor or Guiding Care exp preferred. • Ability to analyze contractual SLAs and KPIs • Ability to effectively communicate and collaborate with a remote team • Candidates may be required to go through a pre-employment criminal background check.

🏖️ Benefits

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