Claims Quality Auditor
Core
Audit enrollment, disenrollment, eligibility, and plan/PCP change transactions for health plan customers to ensure accuracy and compliance with CMS and state standards.
Role type
Quality Auditor (Health Plan Operations)
Builds
Accurate member enrollment data and eligibility segments for health plans
Domain
Health Insurance / Medicaid Managed Care
Deliverable
dashboards & analysis
Required skills
Medicaid managed care enrollment auditing, eligibility redetermination verification, dual-eligible coordination, EDI 834 file review, SLA/KPI analysis, MS Suite (Excel, PowerPoint, Outlook)
Preferred skills
HealthRules Payor, GuidingCare, MLTC enrollment, dual-eligible (Medicare-Medicaid) experience
Responsibilities
Review enrollment file transactions and coordinate with state systems/brokers to confirm effective dates; Verify timely processing of Medicaid eligibility redeterminations; Audit dual-eligible enrollment coordination; Share QA results with associates and coordinate feedback with Team Leads; Collate and report QA performance to management; Maintain currency on CMS and state Medicaid enrollment guidelines.
Seniority
Mid-level, hands-on IC