Claims Quality Auditor (Healthcare)

TL;DR

Claims Quality Auditor (Healthcare): Ensuring the accurate processing of medical claims based on contractual and regulatory requirements with an accent on root cause analysis and process improvement. Focus on conducting pre- and post-payment audits, identifying systemic gaps, and optimizing claims processing guidelines.

Location: Remote (US)

Salary: $44,848 - $61,130 annually

Company

hirify.global is a healthcare company focused on creating a more equitable and sustainable future for employer-sponsored health insurance.

What you will do

• Conduct pre-payment, post-payment, and auto-adjudication audits across multiple benefit plan designs.
• Verify processing, payment, and financial accuracy of claims according to SPDs and regulatory requirements.
• Track audit results and perform trending analysis to identify root causes of process gaps.
• Collaborate with system SMEs to resolve systemic issues and enhance standard processing guidelines.
• Support claims system upgrades and participate in external client audits.
• Mentor examiners through quality improvement plans and training.

Requirements

• Bachelor’s Degree or equivalent professional work experience.
• 2 years of experience auditing medical claims for a health insurer or TPA.
• 5 years of background in medical claims processing.
• Must be based in the US (implied by 401k and US-specific benefits).
• Ability to analyze data and utilize the '5 Whys' to determine root causes.
• Strong independent decision-making, influencing, and analytical skills.

Nice to have

• Previous startup company experience.
• Experience in Payment Integrity.
• Coding certification from AAPC or AHIMA.
• Familiarity with Javelina claims processing software.

Culture & Benefits

• Comprehensive health and wellness benefits, including alternative medicine coverage.
• Generous PTO and up to 16 weeks of paid parental leave.
• 401k program and education reimbursement.
• Transportation perks and paid 'paw-ternity' leave.
• Non-hierarchical, merit-driven culture within a high-performance environment.