Claims Quality Auditor

Responsibilities

• Perform audits of Medicaid managed care and managed long-term care (MLTC) claims transactions processed by health plan administration associates for a specific customer
• Be responsible for following the customer quality process and tools for audit and rebuttal process
• Audit claims for long-term services and supports (LTSS), including home care, personal care, and other community-based service claim types, for accuracy and compliance with plan and regulatory requirements
• Audit claims involving dual-eligible (Medicare-Medicaid) members to confirm accurate coordination of benefits and correct payer sequencing
• Share QA results with individual associates, coordinate with operational Team Leads and managers to provide feedback to individuals, clearly identifying errors and opportunities of improvement
• Collate, compile and report both team and individual associates' QA performance to management and individuals
• Provide inputs to Training team and Team Leads for up-to-date written processing instruction/refresher training needs
• Participate in UST HealthProof's or the customer's Audit the Auditor program
• Participate in semi-annual or annual auditor calibration activities
• Maintain currency on CMS and state Medicaid managed care claims processing rules, including guidelines for managed long-term care (MLTC) plans and dual-eligible integrated plans (D-SNP/MAP)

Preferred

• managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) claims auditing experience strongly preferred
• HealthRules® Payor or GuidingCare® experience preferred

Benefits

• Remote, US
• Glassdoor
• 3.4
• Healthcare technology solutions connecting health plans, providers, and patients.
• Boston, Massachusetts, USA
• http://www.healthedge.com
• Late Stage
• Total Funding
• $97.78M
• Key Investors
• Medica
• Oaktree Specialty Lending
• Psilos Group
• 2025-04-08
• Acquired
• 2020-03-09
• Private Equity
• 2017-07-14
• Series Unknown· $34M
• Leadership Team
• Alex Saltzman
• Chief of Staff to the CEO & Senior Vice President of Corporate Development
• Kevin Adams
• Chief Executive Officer
• Recent News
• Washington Technology
• CMS chooses finalists for Medicare claims processing competition
• 2026-06-03
• Newswire
• Payer-to-Payer API Reality Gap Report Finds Most Exchanged Data Still Fails at the Point of Operational Use

Qualifications

• High School Diploma or GED required
• 3 years health plan claims auditing operations experience required
• Medicaid managed care claims auditing experience required
• Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook
• Ability to analyze contractual SLAs and KPIs
• Ability to effectively communicate and collaborate with a remote team
• Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) claims auditing experience strongly preferred
• HealthRules® Payor or GuidingCare® experience preferred
• 3 years health plan claims auditing operations experience required.

Required skills

• Contractual SLA and KPI Analysis, Dual-Eligible (Medicare-Medicaid) Claims Auditing, GuidingCare, Health Plan Claims Auditing, HealthRules Payor, Managed Long-Term Care (MLTC) Claims Auditing, Medicaid Managed Care Claims Auditing, Microsoft PowerPoint

Preferred skills

• HealthRules® Payor or GuidingCare® experience preferred

Experience

• 3+ years