Claims Quality Auditor

Aim

We’re looking for a Claims Quality Auditor to ensure the accurate and correct processing of medical claims.

Responsibilities

• 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.
• 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 sing efforts for claims system upgrades, as needed.
• 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

Extra Credit

• Previous startup company experience
• Previous Payment Integrity experience
• Coding certification from AAPC or AHIMA
• Familiarity with Javelina claims processing software

Qualifications

• Ability to articulate findings and defend methodology used to produce findings
• Commitment to our core competencies of being authentic, curious, creative, empathetic and outcome oriented

Skills

• Strong analytical skills
• Excellent communication skills
• Independent decision-making and influencing skills

Benefits

Our unique benefits program includes alternative medicine coverage, flexible PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, transportation perks, education reimbursement, and 2 days of paid paw-ternity leave.