Claims Quality Auditor

HealthEdge Software, Inc.; United States; Remote; USD 44,000 - 50,000; Full time

Job summary

HealthEdge Software, Inc. is seeking a Claims Quality Auditor to perform audits of health plan transactions, including claims, enrollment, and premium billing, with oversight from the Lead Auditor or Quality Audit Manager.

The role supports improvements by identifying errors and opportunities for optimization in a remote, US-based environment. Candidates need a high school diploma or GED and at least 3 years of health plan claims auditing experience; Medicaid auditing experience is a plus.

Qualifications

• 3 years health plan claims auditing operations experience required.
• High School Diploma or GED required.
• Proficiency in MS Office (Excel, PowerPoint, Outlook)
• HealthRules Payor or Guiding Care experience preferred.
• Ability to analyze contractual SLAs and KPIs (remote team)

Responsibilities

• Audit transactions processed by health plan administration associates for a specific customer.
• Follow customer quality process and tools for audit and rebuttal processes.
• Share QA results with associates and provide feedback to improve accuracy.
• Collate and report QA performance to management and individuals.
• Provide inputs to Training team for updates to processing instructions.

Skills

Attention to detail

Effective communication

Remote collaboration

Education

High School Diploma or GED

Tools

MS Suite

Excel

PowerPoint

Outlook

Job description

Overview

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations that helps our customers achieve affordable, equitable health care for all. We have a strong global presence, with a workforce of over 4,000 people built on a foundation of simplicity, integrity, people-centricity, and leadership.

You Are

UST HealthProof is looking for a Claims Quality Auditor with health plan claims administration operations experience. This role will report 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 will interact with the client audit team and operational managers daily to report on audit findings, which have an impact on production and quality. This role requires the ability to work both independently with limited supervision and collaboratively in a team environment.

The Opportunity

• Perform audit of transactions processed by health plan administration associates for a specific customer.
• Be responsible for following 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 of improvement.
• Collate, compile and reports 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 customers’ 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.

What You Need

• 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 Compensation can differ depending on factors including but not limited to the specific office location, role, skill set, education, and level of experience.

Geographic Responsibility: Remote, US

Type of Employment: Full-time, permanent

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

• 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.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

#LI-Remote

** 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 bedeterminedduring the interview process and is based on a combination of factors including, but not limited to,your skills, experience,qualificationsand education.