Quality Review/Audit Specialist - Remote

Overview

The Quality Review/Audit Specialist will ensure compliance with healthcare regulations through claims audits and performance monitoring while working remotely.

In Short

• Conduct audits for healthcare claims compliance.
• Review audit packages and claims reports.
• Coordinate with provider groups on claims and disputes.
• Perform onsite and virtual audits.
• Analyze medical claims for regulatory adherence.
• Prepare detailed audit reports.
• Document corrective actions and conduct re-audits.
• Present audit results to oversight committees.
• Collaborate with various functional areas.
• Monitor self-reported statistics for compliance.

Requirements

• Bachelor’s degree preferred.
• 3+ years of claims auditing experience.
• Strong knowledge of claims payment methodologies.
• Proficiency in Microsoft Word and Excel.
• Excellent interpersonal and communication skills.
• Knowledge of California Knox-Keene Act is a plus.

Benefits

• Comprehensive healthcare coverage.
• 401(k) retirement plan with company match.
• Paid time off and company holidays.
• Tuition reimbursement and career development programs.
• Employee wellness programs and mental health support.
• Opportunities for advancement within a global organization.