Quality Auditor - Health Plan

Job Summary

To ensure compliance and enhance operational quality, the full-time Quality Auditor - Health Plan will perform routine and targeted audits across various health plan operations remotely, focusing on Claims, Grievances and Appeals, Enrollment, and Provider Data.

Key responsibilities

• Conduct routine and targeted operational quality audits to ensure compliance with regulatory requirements and internal policies
• Monitor quality and accuracy, identifying opportunities for improvements to enhance member and provider experience
• Collaborate with other business units to review and correct processing errors while maintaining efficient operations

Required qualifications

• Associate's degree preferred or equivalent experience
• 3+ years of auditing experience in health plans or managed care organizations, specifically in Claims, Grievances and Appeals, and Enrollment
• Proficiency in processing/auditing for Medicare and Medicaid plans
• Strong knowledge of CMS requirements regarding auditing processes
• Completion of health insurance training and knowledge of medical terminology or equivalent experience