Senior Auditor, Healthcare Claims

Curative HR LLC • Austin, TX

13h • $95,000 - $120,000 • Remote

About The Position

The Senior Auditor, Healthcare Claims is responsible for leading and executing comprehensive claims quality, compliance, and audit programs for the Health Plan. This role supports operational excellence through detailed auditing of professional, institutional, and ancillary healthcare claims across Commercial lines of business. This position plays a critical role in identifying root causes of claims errors, improving adjudication accuracy, reducing administrative rework, and supporting automation initiatives that increase auto-adjudication rates and operational scalability. The Senior Auditor partners closely with Claims Operations, Configuration, Payment Integrity, Compliance, Provider Operations, Technology, and Vendor Management teams to develop sustainable quality programs that minimize defects and strengthen regulatory compliance. The ideal candidate combines deep healthcare claims expertise with strong analytical skills, operational insight, and a continuous improvement mindset.

Requirements

• Bachelor’s degree in Healthcare Administration, Business, Health Information Management, or related field
• 7+ years of healthcare claims operations, auditing, payment integrity, or quality assurance experience within a health plan, managed care organization, TPA, or payer environment
• Strong experience auditing Commercial, Medicare, and/or Medicaid claims
• Experience performing random sampling audits and targeted compliance reviews
• Experience analyzing root causes of claims processing errors and implementing corrective actions
• Experience supporting regulatory audits and compliance initiatives
• Strong understanding of provider reimbursement methodologies and claims payment workflows
• Deep understanding of healthcare claims lifecycle and adjudication processes
• Knowledge of CMS, HIPAA, NCQA, state prompt-pay, and regulatory requirements
• Strong understanding of: ICD-10, CPT/HCPCS coding, DRG/APC methodologies, Fee schedules, Coordination of Benefits (COB), Provider contract reimbursement methodologies
• Familiarity with payment integrity concepts including overpayment recovery, fraud/waste/abuse controls, and claims editing logic
• Experience with claims platforms such as HealthEdge, Facets, QNXT, EPIC Tapestry, Javelina, or similar systems
• Advanced analytical and reporting skills using Google Sheets, SQL, Streamlit, Snowflake, Claude, N8N, and similar tools
• Strong organizational, documentation, and communication skills
• Strong analytical and critical thinking capabilities
• Continuous improvement mindset with strong operational awareness
• Ability to influence operational teams and drive accountability
• Excellent written and verbal communication skills
• Ability to manage multiple priorities in a fast-paced environment
• Detail-oriented with strong investigative and problem-solving skills
• Collaborative and cross-functional partnership approach

Nice To Haves

• Master’s degree in Healthcare Administration, Business Administration, or related field
• Professional certifications such as CPC, CPMA, CFE, RHIT, RHIA, Six Sigma, or Healthcare Quality certifications
• Experience in a high-growth or rapidly scaling health plan environment
• Experience improving auto-adjudication rates and claims automation initiatives
• Experience with delegated oversight and vendor auditing
• Experience supporting claims system implementations or configuration testing

Responsibilities

• Design and implement an enterprise claims quality assurance program focused on defect reduction and operational excellence.
• Develop statistically valid sampling methodologies and quality scorecards.
• Establish auditing frameworks that support continuous improvement and measurable quality outcomes.
• Create audit dashboards and reporting that provide actionable operational insights to leadership.
• Partner with operational leaders to implement corrective actions and improve first-pass accuracy.
• Support training and coaching initiatives to improve examiner consistency and claims quality performance.
• Perform comprehensive audits of professional, institutional, behavioral health, and ancillary claims to validate adjudication accuracy, contract compliance, and regulatory adherence.
• Conduct random sampling audits, targeted audits, focused reviews, and high-risk claims analysis across all lines of business.
• Review claims for benefit application, coding accuracy, pricing logic, provider reimbursement methodology, authorization requirements, and regulatory compliance.
• Identify trends, root causes, and systemic issues contributing to payment inaccuracies, provider abrasion, or operational inefficiencies.
• Validate configuration accuracy for claims edits, pricing, fee schedules, accumulators, and benefit setup.
• Audit outsourced vendors, delegated entities, and third-party administrators supporting claims operations.
• Monitor operational performance metrics including financial accuracy, procedural accuracy, inventory aging, rework rates, and turnaround time.
• Support internal and external regulatory audits involving CMS, state Departments of Insurance, Medicaid agencies, NCQA, HIPAA, and delegated oversight requirements.
• Ensure compliance with prompt-pay regulations, provider dispute timeliness standards, and claims processing requirements.
• Assist with corrective action plans (CAPs), remediation tracking, and audit response documentation.
• Develop and maintain audit policies, procedures, and standard operating documentation.
• Maintain audit readiness and support market expansion activities.
• Partner with Claims Operations, Configuration, Product, and Technology teams to identify automation opportunities that increase auto-adjudication rates and reduce manual intervention.
• Analyze recurring audit findings to improve claims editing logic, workflows, and configuration rules.
• Support implementation and optimization of AI-enabled claims review, workflow automation, and advanced editing technologies.
• Participate in system implementations, upgrades, testing, and configuration validation.
• Drive continuous improvement initiatives focused on reducing administrative cost and increasing operational scalability.
• Collaborate with Claims Operations, Payment Integrity, Compliance, Provider Relations, Utilization Management, Network Management, and Information Technology teams.
• Serve as a subject matter expert for claims payment accuracy and operational quality initiatives.
• Present audit findings, trends, and recommendations to operational leadership.
• Assist with provider dispute investigations and complex claims escalations.

Benefits

• Curative Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the base plan.)
• $0 copays and $0 deductibles (with completion of our Baseline Visit )
• Preventive and primary care built in
• Mental health support (Rula, Televero, Two Chairs, Recovery Unplugged)
• One-on-one care navigation
• Chronic condition programs (diabetes, weight, hypertension)
• Maternity and family planning support
• 24/7/365 Curative Telehealth
• Pharmacy benefits
• Comprehensive dental and vision coverage
• Employer-provided life and disability coverage with additional supplemental options
• Flexible spending accounts
• Flexible work options: remote and in-person opportunities
• Generous PTO policy plus 11 paid annual company holidays
• 401K for full-time employees
• Generous Up to 8–12 weeks paid parental leave, based on role eligibility.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior