Senior Claims QA Auditor — Quality & Compliance

PIH Health; United States; On-site; USD 32,000 - 51,000; Full time

Job summary

PIH Health seeks a Claims Quality Assurance Auditor to preserve strong relationships with health plans, providers, and members while coordinating audit activities and reporting preliminary non-compliance findings to the CQA manager.

You will oversee audit findings, educate staff on deficiencies, and develop preventative audit controls and root cause analyses to improve timeliness and accuracy of PIH Health claims processing.

Qualifications

• Five (5) to ten years claims processing experience.
• Experience with implementation of Corrective Action Plan (CAP).
• Knowledge of CMS and DHS regulatory requirements.
• High School Diploma or equivalent required.

Responsibilities

• Maintain positive working relationships with internal and external customers and partners.
• Coordinate health plan audits and prepare preliminary results for CQA manager.
• Oversee audit findings and educate claims staff on deficiencies.
• Develop audit control checklists to prevent delays and errors.
• Produce root cause analysis reports to identify trends and feedback to teams.
• Ensure QA programs align with claims operations and other impact areas.
• Research, analyze and resolve complex claims audit issues including denials and disputes.
• Apply CMS/DMHC/DOI guidelines and ensure regulatory compliance.

Skills

Written and verbal communication

Regulatory compliance understanding

Data analysis and trend understanding

Root cause analysis/trends

Independence and self-motivation

Meeting deadlines

Initiative and problem solving

Confidentiality

Customer service

Communication with CQA manager

Education

High School Diploma or equivalent

Bachelor's Degree preferred

Tools

MS Excel

MS Word

Job description

PIH Health seeks a Claims Quality Assurance Auditor to preserve strong relationships with health plans, providers, and members while coordinating audit activities and reporting preliminary non-compliance findings to the CQA manager.

You will oversee audit findings, educate staff on deficiencies, and develop preventative audit controls and root cause analyses to improve timeliness and accuracy of PIH Health claims processing.