Claims Quality Auditor

About the role

UST HealthProof is looking for a Claims Quality Auditor with health plan claims administration operations experience. This role reports to the Lead Auditor or Quality Audit Manager. The Quality Auditor performs audits of an assigned group of transactions (claims, enrollment, premium billing, paper claims and correspondence scanning) and interacts with the client audit team and operational managers daily to report on audit findings, which have an impact on production and quality. The role requires the ability to work both independently with limited supervision and collaboratively in a team environment.

Responsibilities

• Perform audit of transactions processed by health plan administration associates for a specific customer.
• Follow the customer quality process and tools for audit and rebuttal process.
• Share QA results with individual associates, coordinate with operational Team Leads and managers to provide feedback to individuals, clearly identifying errors and opportunities for improvement.
• Collate, compile and report both team and individual associates’ QA performance to management and individuals.
• Provide inputs to Training team and Team Leads for up-to-date written processing instruction/refresher training needs.
• Participate in UST HealthProof’s or the customer’s Audit the Auditor program.
• Participate in semi-annual or annual auditor calibration activities.
• Maintain currency on CMS claims processing rules and guidelines for Medicare Advantage organizations and ACA Exchange and Off Exchange lines of business.

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 experience preferred.
• Ability to analyze contractual SLAs and KPIs.
• Ability to effectively communicate and collaborate with a remote team.

Pay

The annual US base salary range for this position is $44,000 to $50,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.

Schedule

• Geographic Responsibility: Remote, US
• Type of Employment: Full-time, permanent
• Work Environment: The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Work across multiple time zones in a hybrid or remote work environment. Long periods of time sitting and/or standing in front of a computer using video technology. May require travel dependent on company needs.