Claims Quality Auditor

A Little More About this Role: 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 pre-payment, post-payment, and auto-adjudication audits, including routine to moderately complex claims that cover multiple benefit plan designs

Ensure processing, payment, and financial accuracy of claims by verifying all aspects have been handled correctly according to SPDs, regulatory requirements, and standard operating procedures

Meticulously track and report audit results, including finalized decisions for use in reporting and trending analysis

Responsible for identifying corrections and/or adjustments needed, and to verify corrections and/or adjustments are completed and accurate

Identify and escalate trends based on quality reviews for root cause solutioning, documentation creation and enhancement, and overall process improvement

Investigate and research claim issues and errors to create or improve standard processing guidelines

Participate as a SME and/or partner with system SMEs to identify and report on systemic issues which create ongoing quality concerns

Serve on applicable cross-functional quality committees and work groups to identify and communicate common quality issues, trends, and patterns