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Claims Quality Auditor
- 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.
- Support testing efforts for claims system upgrades, as needed.
- Participate in client external audits.
- Perform any other additional duties as necessary, including processing of claims, creating policies, and training and/or mentoring examiners through quality improvement plans.
- Demonstrate commitment to our core competencies of being authentic, curious, creative, empathetic and outcome oriented.
- 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 determine the true root cause of an issue
- 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 collaboration
- Previous startup company experience
- Previous Payment Integrity experience
- Coding certification from AAPC or AHIMA
- Familiarity with Javelina claims processing software.
Gravie:
In order to create a more equitable and sustainable future for employer-sponsored health insurance, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an above average total rewards package.
The hourly range for this position is $22.04 - $29.39 hourly. Numerous factors including, but not limited to, education, skills, work experience, certifications, etc. will be considered when determining compensation.
Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard health and wellness benefits, Gravie’s package includes alternative medicine coverage, generous PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, transportation perks, education reimbursement, and paid paw-ternity leave.
A Little More About Us:
We know healthcare. Our company was founded and is still led by industry veterans who have started and grown several market-leading companies in the space.
We have raised money from top tier investors who share the same long-term vision as we do of building an industry defining company that will endure over the long run. We are well capitalized.
Our clients love us. Customer satisfaction rates among employees using Gravie health plans consistently rank above 80% – nearly 40 points above the industry average.
Our culture is unique. We tend to be non-hierarchical, merit-driven, opinionated but kind people who thrive working in a high-performance, fast-paced environment. People at Gravie care deeply about making a positive impact in the lives of the people we serve. We may not be the right place for everybody, but if you get energized by doing work every day that focuses on putting consumers at the front of the line, we could be a great place for you. It takes unique people and diverse perspectives to deliver our results. We encourage you to be your authentic self – we like you that way.
We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us.
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