Claims process Auditor

Role Summary: As the Quality Analyst in the healthcare claims process, you will be responsible for monitoring and evaluating claims adjudication and denial management activities to ensure compliance with client SLAs, payer guidelines, regulatory requirements, and internal quality standards. You will identify root causes, recommend corrective actions, support training initiatives, and partner with operations to drive continuous improvement in accuracy, turnaround time, and first-pass yield.

Primary Job Responsibilities:

• Claims Auditing: Review and audit submitted claims to ensure they are accurate, complete, and comply with internal operational guidelines and healthcare regulations (like HIPAA).
• Compliance and Accuracy: Verify that claims adhere to proper coding (ICD, CPT, HCPCS) and that all necessary documentation is present and correct.
• Error Identification & Correction: Identify coding, submission, and documentation errors, and provide corrective guidance to claims processing teams.
• Performance Analysis: Analyze denial trends, recurring errors, and other quality metrics to identify systemic issues.
• Process Improvement: Utilize methodologies such as Root Cause Analysis (RCA) and Corrective & Preventive Actions (CAPA) to address recurring issues and prevent future errors.
• Reporting: Prepare detailed reports on audit findings, quality metrics, trends, and recommended corrective actions for stakeholders.
• Collaboration: Work closely with coders, billers, training teams, and other departments to implement corrective actions and improve overall claim processing quality.
• Regulatory Updates: Stay informed about changes in healthcare regulations, coding standards, and best practices in the industry.
• Quality Assurance: Assist in developing and refining quality assurance processes, tools, and documentation.

Required Skills & Qualifications:

• Analytical Skills: Strong ability to analyze data, identify patterns, and make data-driven recommendations.
• Technical Skills: Proficiency with quality tools, such as the 7 QC tools, Six Sigma methodologies.
• Attention to Detail: Meticulous attention to detail is crucial for accurately reviewing complex claim information.
• Communication: Excellent written and verbal communication skills to provide clear feedback and reports to various teams.
• Healthcare Knowledge: Deep understanding of healthcare claims processes, medical coding (ICD, CPT), and relevant regulations.
• Problem-Solving: Strong problem-solving skills to address errors and implement effective solutions.

Required Qualifications:

• Experience working in healthcare claims processing, medical billing, or denial management within a BPO or provider/payer environment.
• Proven experience in quality assurance or auditing for claims, with familiarity in evaluating EOBs, ERA/RAs, and remittance advice.
• Strong knowledge of medical coding (CPT, ICD-10, HCPCS) and claim adjudication principles.
• Working knowledge of payer policies, Medicare/Medicaid rules, and commercial plan variations in the U.S. market.
• Proficiency with claims management systems, EHRs, and QA tools (specify tools used by your organization where applicable).
• Strong analytical skills and experience using Excel or BI/dashboarding tools to analyze trends and present findings

Working Conditions:

• May require occasional extended hours to meet client deadlines or support peak processing windows.
• Must adhere to strict confidentiality and data protection protocols.

Compensation & Benefits: Opportunities for career progression into Quality Lead, Quality Manager, or Operations roles.

Job Type: Full-time

Pay: $ $35.00 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• Health insurance

Application Question(s):

• How many years of Claims Auditing experience do you have?

Work Location: Remote