Claims Quality Auditor

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.

UST HealthProof is looking for a Claims Quality Auditor with health plan claims administration operations experience, ideally within Medicaid managed care. This role will report to the Lead Auditor or Quality Audit Manager. The Quality Auditor performs audits of an assigned group of transactions (claims, enrollment, premium billing, paper claims and correspondence scanning) across Medicaid managed care, managed long-term care (MLTC), and dual-eligible (Medicare-Medicaid) lines of business, 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.

• 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).

• High School Diploma or GED required.
• 3 years health plan claims auditing operations experience required.
• Medicaid managed care claims auditing experience required; managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) claims auditing experience strongly 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.

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:  

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

#LI-Remote 

**The annual US base salary range for this position is $44,000 to $50,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.