Remote Claims Quality Auditor - Medicaid/MLTC

HealthEdge; United States; À distance; USD 44 000 - 50 000; Plein temps

Résumé du poste

HealthEdge is seeking a Claims Quality Auditor in the United States to perform audits of Medicaid managed care and MLTC claims, ensuring accuracy and regulatory compliance. The role reports to the Lead Auditor or Quality Audit Manager and supports cross-functional teams in a remote, multi-time-zone environment.

The ideal candidate has 3 years of health plan claims auditing experience, proficiency in MS Office, and familiarity with CMS/state rules.

Qualifications

• High School Diploma or GED required.
• 3 years health plan claims auditing operations experience required.
• Medicaid managed care claims auditing experience preferred.
• Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook.
• HealthRules Payor or GuidingCare experience preferred.
• Ability to analyze contractual SLAs and KPIs.
• Ability to effectively communicate and collaborate with a remote team.

Responsabilités

• Perform audits of Medicaid managed care and managed long-term care (MLTC) claims 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.
• Audit claims for long-term services and supports (LTSS), including home care, personal care, and other community-based service claim types, for accuracy and compliance with plan and regulatory requirements.
• Audit claims involving dual-eligible (Medicare-Medicaid) members to confirm accurate coordination of benefits and correct payer sequencing.
• 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 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 and state Medicaid managed care claims processing rules, including guidelines for managed long-term care (MLTC) plans and dual-eligible integrated plans (D-SNP/MAP).

Connaissances

Health plan claims auditing

MS Office proficiency

Remote collaboration

Formation

High School Diploma or GED

Outils

Excel

PowerPoint

Outlook

HealthRules Payor

GuidingCare

Description du poste

HealthEdge is seeking a Claims Quality Auditor in the United States to perform audits of Medicaid managed care and MLTC claims, ensuring accuracy and regulatory compliance. The role reports to the Lead Auditor or Quality Audit Manager and supports cross-functional teams in a remote, multi-time-zone environment.

The ideal candidate has 3 years of health plan claims auditing experience, proficiency in MS Office, and familiarity with CMS/state rules.