Claims Quality Inspector

Job Summary

To ensure compliance and accuracy, the full-time remote Claims Quality Inspector will conduct thorough reviews of adjudicated claims and enrollment entries, maintaining knowledge of corporate guidelines and protocols.

Key responsibilities:

• Conduct accurate and timely quality reviews of claim adjudication activities and membership eligibility
• Document findings in the QC tracking system and communicate error determinations clearly
• Collaborate with team members to meet quality, productivity, and timeliness standards set by management

Required qualifications:

• High School Diploma or GED required; Bachelor's degree or claims adjudication/medical billing certification preferred
• At least 2 years of experience in a Claims or QC/Inspector role within the managed care industry, or 5 years processing medical claims
• Prior experience in Medicare, Medicaid, or regulated Managed Care environments is preferred
• Familiarity with Facets claims administration platform is desirable
• Pre-employment background check required