Claims Quality Auditor

Overview

HealthEdge® offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations that helps our customers achieve affordable, equitable health care for all. We have a strong global presence, with a workforce of over 4,000 people built on a foundation of simplicity, integrity, people-centricity, and leadership.

You Are

UST HealthProof is looking for an Enrollment Quality Auditor with health plan Medicaid member enrollment and eligibility operations experience. This role will report to the Lead Auditor or Quality Audit Manager. The Quality Auditor performs audits of an assigned group of enrollment transactions (new enrollment, disenrollment, eligibility redeterminations, PCP and plan changes, retroactive enrollment actions) and will interact with the client audit team and operational managers daily to report on audit findings, which have an impact on production and quality. This role requires the ability to work both independently with limited supervision and collaboratively in a team environment.

The Opportunity

Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates for a specific customer.

Be responsible for following the customer quality process and tools for audit and rebuttal process. Review enrollment (834) file transactions and coordination with state enrollment systems and enrollment brokers to confirm accuracy of member effective dates, retroactive enrollment/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, coordinate with operational Team Leads and managers to provide feedback to individuals, clearly identifying errors and opportunities for improvement.

Collate, compile and report both team and individual associates' QA performance to management and individuals.

Provide inputs to the Training team and Team Leads for up-to-date 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 (MLTC) enrollment/disenrollment rules.

What You Need

High School Diploma or GED required.

3 years health plan enrollment/eligibility auditing operations experience required.

Medicaid managed care enrollment auditing experience preferred; managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience strongly preferred.

Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook.

HealthRules® Payor or GuidingCare® experience preferred; familiarity with EDI 834 enrollment transactions and eligibility verification systems a plus.

Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness.

Ability to effectively communicate and collaborate with a remote team.

Geographic Responsibility: Remote, US

Type of Employment: Full-time, permanent

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job:

The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Work across multiple time zones in a hybrid or remote work environment.

Long periods of time sitting and/or standing in front of a computer using video technology.

May require travel dependent on company needs.

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990. Candidates may be required to go through a pre-employment criminal background check.

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities.

#LI-Remote

** The annual US base salary range for this position is $44,000 to $58,000 . This salary range may cover multiple career levels at HealthEdge. Final compensation will be determined during the interview process and is based on a combination of factors including, but not limited to, your skills, experience, qualifications and education.