Claims Quality Auditor

HealthEdge•Remote,

2d•$44,000 - $58,000•Remote

About The Position

HealthEdge/UST HealthProof is seeking a quality auditor with health plan Medicaid member enrollment and eligibility operations experience. The role audits assigned enrollment transactions, including new enrollment, disenrollment, eligibility redeterminations, PCP and plan changes, and retroactive enrollment actions. The auditor follows customer quality and rebuttal processes, works with client audit teams and operational managers, and reports findings that affect production and quality. The position requires independent work with limited supervision as well as collaboration with a team. The auditor reviews enrollment transactions and supporting state-system and broker information, checks processing against applicable CMS and state requirements, communicates findings and improvement opportunities, reports team and individual performance, and contributes to training materials and calibration activities. The position is remote in the United States, with work across multiple time zones and possible travel depending on company needs.

Requirements

High school diploma or GED.
Three years of health plan enrollment/eligibility auditing operations experience.
Proficiency with Microsoft Office, specifically Excel, PowerPoint, and Outlook.
Ability to analyze contractual SLAs and KPIs, particularly those related to enrollment processing timeliness.
Ability to communicate and collaborate effectively with a remote team.

Nice To Haves

Medicaid managed care enrollment auditing experience.
Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience.
Experience with HealthRules Payor or GuidingCare.
Familiarity with EDI 834 enrollment transactions and eligibility verification systems.

Responsibilities

Audit enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates for a specific customer.
Follow the customer's quality process and tools for audits and rebuttals.
Review enrollment (834) file transactions and coordinate with state enrollment systems and enrollment brokers to confirm member effective dates, retroactive enrollment or disenrollment, and eligibility segments.
Verify timely and accurate processing of Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards.
Audit dual-eligible Medicare-Medicaid enrollment coordination, including alignment of Medicare and Medicaid eligibility segments and coordination of benefits.
Share QA results with individual associates and coordinate feedback with operational Team Leads and managers, identifying errors and improvement opportunities.
Compile and report team and individual associate QA performance to management and individuals.
Provide inputs to the Training team and Team Leads for current written processing instructions and 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 Medicaid managed care enrollment guidelines, applicable state Medicaid enrollment requirements, and managed long-term care enrollment and disenrollment rules.