Claims Quality Auditor – Regulatory Compliance

Lsmamso; California (MO); On-site; USD 70,000 - 90,000; Full time

Job summary

A leading healthcare organization is seeking a Quality Control Auditor – Claims Management to ensure accuracy and compliance in claims processing. The role involves auditing claims activities, identifying trends, and ensuring adherence to federal and state regulations. Candidates should have substantial experience in managed care claims auditing with a focus on detail and regulatory standards. Preferred qualifications include relevant degrees and certifications. This position supports operational improvement while minimizing financial risk.

Qualifications

• Minimum five years of managed care claims auditing or related experience.
• Preferred certifications include CPC, CPMA, or CPCO.
• Strong knowledge of CPT, HCPCS, ICD-10, and reimbursement methodologies.

Responsibilities

• Perform detailed audits of claims processing activities.
• Evaluate claims adjudication performed by Claims Examiners.
• Support managed care compliance through auditing claims.

Skills

Managed care claims processing knowledge

Analytical and problem-solving skills

Attention to detail

Communication skills

Proficiency with claims systems

Education

High School Diploma or equivalent

Associate’s or Bachelor’s degree in relevant field

Tools

EZ Cap

Microsoft Office

Job description

A leading healthcare organization is seeking a Quality Control Auditor – Claims Management to ensure accuracy and compliance in claims processing. The role involves auditing claims activities, identifying trends, and ensuring adherence to federal and state regulations. Candidates should have substantial experience in managed care claims auditing with a focus on detail and regulatory standards. Preferred qualifications include relevant degrees and certifications. This position supports operational improvement while minimizing financial risk.