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Claims Quality Auditor

4 months ago

Minneapolis, Minnesota, United States Gravie Full time
Hi, we're Gravie.

Our mission is to improve the way people purchase and access healthcare through innovative, consumer-centric health benefit solutions that people can actually use.

Our industry-changing products and services are developed and delivered by a diverse group of unique people. We encourage you to be your authentic self - we like you that way.
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.


You will:

  • Conduct routine to moderately complex audits, covering multiple benefit plan designs, comparing claims results against SPDs, regulatory requirements, and departmental procedures
  • Research claim processing problems and errors to determine their origin and appropriate resolution
  • Meticulously track and trend audit results, providing regular feedback to management
  • Partner with system SMEs to identify and report on systemic issues which create ongoing quality concerns
  • Conduct audits of claims payments to ensure payments are being issued timely and accurately
  • 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 auditsYou bring:

  • 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 root out true root cause
  • 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 collaborationExtra credit:

  • Previous startup company experience
  • Previous Payment Integrity experience
  • Coding certification from AAPC or AHIMA
  • Familiarity with Javelina claims processing softwareCompetitive pay is standard. Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard benefits, Gravie's package includes alternative medicine coverage, flexible PTO, 16 weeks paid parental leave, paid holidays, cell phone reimbursement, education reimbursement, and 1 week of paid paw-ternity leave just to name a few.