Claims Quality Auditor

About the role

The Claims Quality Auditor ensures that medical claims are processed accurately, efficiently, and in compliance with contractual, regulatory, and operational standards. Working in a fast‑paced, mission‑driven environment, you will identify quality gaps, uncover root causes, and drive improvements that enhance claims accuracy and overall operational performance.

Key responsibilities

• Conduct pre‑payment, post‑payment, and automated adjudication audits of routine to moderately complex medical claims.
• Verify claims processing, payments, and financial accuracy against plan documents, regulations, and SOPs.
• Track, document, and report audit findings, trends, and quality performance insights.
• Identify required corrections or adjustments and ensure accurate completion.
• Investigate claims issues, determine root causes, and recommend preventive solutions.
• Analyze quality trends and support process improvements, documentation updates, and operational enhancements.
• Partner with system experts and cross‑functional teams to resolve system‑related quality issues.
• Participate in quality committees, external audits, testing initiatives, and process‑improvement projects.
• Support claims operations through policy creation, training, mentoring, and quality‑improvement activities.

Required profile

• Bachelor’s degree or equivalent professional experience.
• Minimum of 2 years auditing medical claims within a health insurer.
• Strong attention to detail, analytical capabilities, and independent judgment.
• Excellent collaboration and communication skills.
• Commitment to continuous improvement and alignment with values of authenticity, curiosity, creativity, empathy, and measurable outcomes.

Required skills