Senior Auditor, Healthcare Claims

Job title: Senior Auditor, Healthcare Claims

About the Role Senior Auditor, Healthcare Claims is responsible for leading and executing comprehensive claims quality, compliance, and audit programs for the Health Plan. This remote role supports operational excellence through detailed auditing of professional, institutional, and ancillary healthcare claims across Commercial lines of business. This is a remote position.

What You'll Do

• Design and implement an enterprise claims quality assurance program focused on defect reduction and operational excellence.
• Develop statistically valid sampling methodologies and quality scorecards.
• Establish auditing frameworks that support continuous improvement and measurable quality outcomes.
• Create audit dashboards and reporting that provide actionable operational insights to leadership.
• Partner with operational leaders to implement corrective actions and improve first-pass accuracy.
• Support training and coaching initiatives to improve examiner consistency and claims quality performance.
• Perform comprehensive audits of professional, institutional, behavioral health, and ancillary claims to validate adjudication accuracy, contract compliance, and regulatory adherence.
• Conduct random sampling audits, targeted audits, focused reviews, and high-risk claims analysis across all lines of business.
• Review claims for benefit application, coding accuracy, pricing logic, provider reimbursement methodology, authorization requirements, and regulatory compliance.
• Identify trends, root causes, and systemic issues contributing to payment inaccuracies, provider abrasion, or operational inefficiencies.
• Validate configuration accuracy for claims edits, pricing, fee schedules, accumulators, and benefit setup.
• Audit outsourced vendors, delegated entities, and third-party administrators supporting claims operations.
• Monitor operational performance metrics including financial accuracy, procedural accuracy, inventory aging, rework rates, and turnaround time.
• Support internal and external regulatory audits involving CMS, state Departments of Insurance, Medicaid agencies, NCQA, HIPAA, and delegated oversight requirements.
• Ensure compliance with prompt-pay regulations, provider dispute timeliness standards, and claims processing requirements.
• Assist with corrective action plans (CAPs), remediation tracking, and audit response documentation.
• Develop and maintain audit policies, procedures, and standard operating documentation.
• Maintain audit readiness and support market expansion activities.
• Partner with Claims Operations, Configuration, Product, and Technology teams to identify automation opportunities that increase auto-adjudication rates and reduce manual intervention.
• Analyze recurring audit findings to improve claims editing logic, workflows, and configuration rules.
• Support implementation and optimization of AI-enabled claims review, workflow automation, and advanced editing technologies.
• Participate in system implementations, upgrades, testing, and configuration validation.
• Drive continuous improvement initiatives focused on reducing administrative cost and increasing operational scalability.
• Collaborate with Claims Operations, Payment Integrity, Compliance, Provider Relations, Utilization Management, Network Management, and Information Technology teams.
• Present audit findings, trends, and recommendations to operational leadership.
• Assist with provider dispute investigations and complex claims escalations.

What We're Looking For

• Education: Bachelor’s degree in Healthcare Administration, Business, Health Information Management, or related field. Preferred: Master’s degree in Healthcare Administration, Business Administration, or related field.
• Professional certifications such as CPC, CPMA, CFE, RHIT, RHIA, Six Sigma, or Healthcare Quality certifications.
• Experience: 7+ years of healthcare claims operations, auditing, payment integrity, or quality assurance experience within a health plan, managed care organization, TPA, or payer environment.
• Strong experience auditing Commercial, Medicare, and/or Medicaid claims.
• Experience performing random sampling audits and targeted compliance reviews.
• Experience analyzing data and trends to identify root causes and opportunities.

Nice to Have

• Master’s degree (preferred).
• Professional certifications such as CPC, CPMA, CFE, RHIT, RHIA, Six Sigma, or Healthcare Quality certifications (preferred).