Claims Quality Auditor
Core
Audit Medicaid managed care, managed long-term care (MLTC), and dual-eligible claims transactions for accuracy and compliance with plan and regulatory requirements.
Role type
Claims Quality Auditor
Builds
Audit findings and QA reports for health plan operations
Domain
Health insurance / Medicaid managed care / Long-term care
Deliverable
dashboards & analysis
Required skills
Medicaid managed care claims auditing, MLTC claims auditing, dual-eligible claims auditing, claims transaction auditing, regulatory compliance analysis, SLA and KPI analysis, MS Excel, MS PowerPoint, MS Outlook
Preferred skills
HealthRules Payor experience, GuidingCare experience, managed long-term care (MLTC) experience, dual-eligible (Medicare-Medicaid) experience
Responsibilities
Perform audits of claims transactions processed by health plan administration associates, follow customer quality process and tools for audit and rebuttal, audit claims for long-term services and supports (LTSS), audit claims involving dual-eligible members to confirm accurate coordination of benefits, share QA results with associates and coordinate with operational Team Leads, collate and report QA performance to management, provide inputs to Training team for processing instruction needs, participate in auditor calibration activities, maintain currency on CMS and state Medicaid managed care claims processing rules