Senior Quality Auditor
Core
Audits and validates routine pre and post payment claims to ensure correct adjudication and compliance with corporate policies and regulatory guidelines.
Role type
Senior Quality Auditor (Claims Processing)
Builds
Validated claims data and compliance reports for medical review and cost saving initiatives
Domain
Health Insurance / Claims Adjudication
Required skills
Claims adjudication, Provider data management, Regulatory compliance, Claims research, Data analysis, Reporting
Preferred skills
Knowledge of Health Net products, Contract and benefit plan coding, Health insurance regulations
Technologies
Claims processing systems
Responsibilities
Audits provider data loaded into claims processing systems, Researches claims and enrollment discrepancies, Documents and reports audit results, Summarizes findings and recommendations in reports, Communicates with claims department to improve processing, Maintains department statistics for quality improvement
Seniority
Senior, hands-on IC