Claims Quality Auditor

The Claims Quality Auditor is responsible for monitoring claims accuracy, identifying improvement opportunities, and supporting quality initiatives across claims operations. The role requires strong attention to detail, analytical capabilities, and the ability to collaborate with internal teams to resolve issues and improve processes.

• Conduct pre-payment, post-payment, and automated adjudication audits across routine to moderately complex medical claims and benefit plan designs.
• Verify claims processing, payments, and financial accuracy according to plan documents, regulatory requirements, and standard operating procedures.
• Track, document, and report audit findings, decisions, trends, and quality performance insights.
• Identify required corrections or adjustments and ensure they are completed accurately and effectively.
• Investigate claims issues, determine root causes, and recommend solutions to prevent recurring errors.
• Analyze quality trends and escalate findings to support process improvements, documentation updates, and operational enhancements.
• Partner with system experts and cross-functional teams to identify system-related issues impacting claims quality.
• Participate in quality committees, external audits, testing initiatives, and process improvement projects.
• Support claims operations when needed, including policy creation, training, mentoring, and quality improvement activities.
• Demonstrate strong alignment with values centered around authenticity, curiosity, creativity, empathy, and achieving measurable outcomes.

Requirements:

The ideal candidate brings strong medical claims expertise, auditing experience, and the ability to analyze complex information while communicating findings clearly. Success in this role requires independent judgment, collaboration skills, and a commitment to continuous improvement.

• Bachelor’s degree or equivalent professional experience.
• Minimum of 2 years of experience auditing medical claims within a health insurer or third-party administrator (TPA) environment.
• Extensive medical claims processing experience, typically around 5 years.
• Ability to analyze data, identify trends, and apply structured root-cause analysis methodologies such as the 5 Whys.
• Knowledge of claims system configuration and operational workflows.
• Ability to clearly communicate audit findings and explain the methodology behind decisions.
• Strong analytical, problem-solving, decision-making, and influencing skills.
• Excellent written and verbal communication abilities.
• Proven ability to collaborate effectively and achieve results across teams.

Preferred qualifications:

• Experience working in a startup environment.
• Background in payment integrity initiatives.
• Coding certification through organizations such as AAPC or AHIMA.
• Familiarity with Javelina claims processing software.

Benefits:

The role offers a competitive compensation package along with benefits designed to support employee wellbeing, growth, and work-life balance.

• Compensation range of $22.04 - $29.39 per hour, depending on experience, skills, education, certifications, and other relevant factors.
• Comprehensive health and wellness benefits.
• Alternative medicine coverage.
• Generous paid time off (PTO).
• Up to 16 weeks of paid parental leave.
• Paid holidays.
• 401(k) retirement program.
• Transportation perks.
• Education reimbursement opportunities.
• Paid paw-ternity leave.
• Opportunities for career development and meaningful work in a mission-driven environment.