Senior Quality Auditor

About the role

Develops and implements effective business solutions through research, audit, and analysis of data and/or business processes. Audits and validates routine pre and post payment claims to determine correct adjudication as well as compliance with corporate policies and procedures, and other applicable regulatory guidelines. Responsible for auditing provider data loaded into the claims processing systems, documenting and reporting audit results, and researching claims and enrollment discrepancies as they are related to provider data. In addition this position may manage a variety of other PDM related projects that typically require advanced knowledge and skills of the provider files and their relation to the claims processing systems. Reviews and supports the claims process for medical review and cost saving initiatives.

Responsibilities

• Maintains department statistics, as necessary, for quality improvement indicators, regulatory agencies and certification bodies.
• Performs routine and moderately complex audits on medical review claims to identify exceptions to established claims adjudication requirements.
• Researches issues from reviewed claims to determine origin and appropriate resolutions.
• Summarizes findings and recommendations in reports for feedback, and distributes to management.
• Communicates with claims department regarding results of audited and/or reviewed claims in order to improve claims processing and resolutions.
• Provides qualified data to incorporate into training programs, policies and procedures.
• Maintains current working knowledge of Health Net products, policies and procedures, contract and benefit plan coding, as well as health insurance industry and regulation and certification standards.

Requirements

• Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future.
• High School Diploma or equivalent; some college coursework preferred.
• Four years general data management experience in an automated claims processing, claims research, or provider maintenance environment.

Applicants for this role have the flexibility to work remotely within the continental United States. To support the needs of the business, preferred schedule is based on Central Standard Time zone or Eastern Standard Time zone.

Pay

$23.23 – $39.61 per hour