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Claims Quality Auditor

8 hours, 31 minutes ago
Anywhere
Full-time
Mid Level
QA Engineer
Quality Assurance and Testing
Apply Now
Gravie

Gravie

Gravie is reinventing health benefits with transparent, affordable solutions like Comfort® plan, ensuring easy access to care for employers and individuals.

Insurance
251-1K
Founded 2013
$177M raised
View All Jobs 18

Description

  • Conduct pre-payment, post-payment, and auto-adjudication audits for routine to moderately complex claims across multiple benefit plan designs.
  • Verify that claim processing, payment, and financial outcomes are accurate according to SPDs, regulatory requirements, and standard operating procedures.
  • Track, document, and report audit results, including finalized decisions used for reporting and trend analysis.
  • Identify needed corrections or adjustments and confirm they are completed accurately.
  • Analyze audit trends to identify root causes, create documentation, and drive process improvements.
  • Investigate claim issues and errors to develop or improve standard processing guidelines.
  • Serve as a subject matter expert and partner with system SMEs to identify systemic quality issues.
  • Participate in cross-functional quality committees and work groups to communicate recurring issues, trends, and patterns.
  • Support claims system upgrade testing and participate in external client audits.
  • Perform additional duties as needed, including claims processing, policy creation, and training or mentoring examiners.

Requirements

  • Bachelor’s degree or equivalent work experience.
  • 2 years of experience auditing medical claims for a health insurer or TPA.
  • 5 years of medical claims processing experience.
  • Ability to analyze data, recognize trends, and use the 5 Whys to identify root causes.
  • Core system configuration knowledge.
  • Ability to articulate findings and defend the methodology used to reach conclusions.
  • Strong independent decision-making, influencing, and analytical skills.
  • Excellent communication skills.
  • Demonstrated success achieving results through collaboration.
  • Previous startup company experience is preferred.
  • Previous payment integrity experience is preferred.
  • AAPC or AHIMA coding certification is preferred.
  • Familiarity with Javelina claims processing software is preferred.

Benefits

  • Hourly pay of $22.05 to $29.40.
  • Standard health and wellness benefits.
  • Alternative medicine coverage.
  • Generous PTO.
  • Up to 16 weeks of paid parental leave.
  • Paid holidays.
  • 401(k) program.
  • Transportation perks.
  • Education reimbursement.
  • Paid paw-ternity leave.

Interested in this position?

Apply directly on the company website

Apply Now

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