Claims Quality Auditor

HealthEdge; United States; Vor Ort; USD 70.000 - 95.000; Vollzeit

Zusammenfassung

HealthEdge is seeking an Enrollment Quality Auditor to join our team. You will audit Medicaid member enrollment and eligibility transactions, ensuring accuracy and compliance with CMS and state timeliness standards.

The role requires collaboration with client audit teams and operational managers, with the ability to work independently and in a team. Responsibilities include reviewing enrollment files (834s), verifying redeterminations, and reporting QA results to leadership, driving continuous

Qualifikationen

• Experience with Medicaid enrollment and eligibility operations.
• Ability to audit enrollment transactions (new enrollment, disenrollment, redeterminations).
• Strong attention to detail and ability to report QA findings clearly.

Aufgaben

• Audit enrollment, disenrollment, eligibility, and plan/PCP change transactions for a specific customer.
• Follow customer quality processes and tools for audit and rebuttal.
• Review 834 file transactions and verify member effective dates and eligibility segments.
• Verify timeliness and accuracy of Medicaid eligibility redeterminations and recertifications.
• Report QA results to associates and management, identifying errors and opportunities for improvement.

Kenntnisse

Audit

Quality assurance

Medicaid enrollment

Enrollment transactions

CMS standards

Jobbeschreibung

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.

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 an Enrollment Quality Auditor with health plan Medicaid member enrollment and eligibility operations experience. This role will report to the Lead Auditor or Quality Audit Manager. The Quality Auditor performs audits of an assigned group of enrollment transactions (new enrollment, disenrollment, eligibility redeterminations, PCP and plan changes, retroactive enrollment actions) 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 audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates for a specific customer.

• Be responsible for following the customer quality process and tools for audit and rebuttal process. Review enrollment (834) file transactions and coordination with state enrollment systems and enrollment brokers to confirm accuracy of member effective dates, retroactive enrollment/disenrollment, and eligibility segments.
• Verify timely and accurate processing of Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards.
• Audit dual-eligible (Medicare-Medicaid) enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits.
• 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.