Claims Quality Auditor

We’re looking for a Claims Quality Auditor. This role will ensure the accurate and correct processing of medical claims, based on contractual obligations and regulatory requirements. The Claims Quality Auditor is tenacious in supporting Gravie’s ability to process claims correctly, the first time. This entails finding potential trouble spots, identifying root cause and shutting down all gaps and process adherence issues to prevent those trouble spots from persisting.

• Conduct pre-payment, post-payment, and auto-adjudication audits, including routine to moderately complex claims that cover multiple benefit plan designs.

• Ensure processing, payment, and financial accuracy of claims by verifying all aspects have been handled correctly according to SPDs, regulatory requirements, and standard operating procedures.

• Meticulously track and report audit results, including finalized decisions for use in reporting and trending analysis. 

• Responsible for identifying corrections and/or adjustments needed, and to verify corrections and/or adjustments are completed and accurate.

• Identify and escalate trends based on quality reviews for root cause solutioning, documentation creation and enhancement, and overall process improvement.

• Investigate and research claim issues and errors to create or improve standard processing guidelines.

• Participate as a SME and/or partner with system SMEs to identify and report on systemic issues which create ongoing quality concerns.

• Serve on applicable cross-functional quality committees and work groups to identify and communicate common quality issues, trends, and patterns.

• Support testing efforts for claims system upgrades, as needed.

• Participate in client external audits.

• Perform any other additional duties as necessary, including processing of claims, creating policies, and training and/or mentoring examiners through quality improvement plans.

• Demonstrate commitment to our core competencies of being authentic, curious, creative, empathetic and outcome oriented.

• Bachelor’s Degree or equivalent work experience

• 2 years of experience auditing medical claims for a health insurer or TPA

• Extensive (5 years) medical claims processing background

• Ability to analyze data and recognize trends; use of the 5 Whys to determine the true root cause of an issue

• Core system configuration knowledge

• Ability to articulate findings and defend methodology used to produce findings

• Strong independent decision-making, influencing, and analytical skills

• Excellent communication skills

• Demonstrated success getting results through collaboration

• Previous startup company experience

• Previous Payment Integrity experience

• Coding certification from AAPC or AHIMA

• Familiarity with Javelina claims processing software.