We are seeking a detail-oriented and analytical Claims Quality Auditor to join our Claims Operations team. The ideal candidate will be responsible for auditing processed claims to ensure accuracy, compliance, and adherence to company policies and regulatory requirements. This role plays a critical part in maintaining quality standards, identifying process improvement opportunities, and supporting operational excellence.
Key Responsibilities
- Audit a sample or 100% of processed claims for data accuracy, pricing, coding, and adjudication correctness.
- Verify that claim approvals and denials comply with company policies, client requirements, and regulatory standards.
- Identify errors, omissions, inconsistencies, and potential fraud indicators within processed claims.
- Provide constructive feedback and coaching to claims processors to improve quality and accuracy.
- Support quality improvement initiatives and recommend process enhancements.
- Ensure compliance with data privacy and confidentiality requirements, including HIPAA and other applicable regulations.
- Prepare and present audit reports to management on a regular basis.
Required Qualifications
- Prior experience in claims processing, claims adjudication, quality assurance, or auditing.
- Strong understanding of claims processing workflows and adjudication rules.
- Knowledge of coding structures such as ICD, CPT, HCPCS, or other industry-relevant coding systems.
- Strong written and verbal communication skills.
- Ability to identify trends, analyze data, and provide actionable recommendations.
- Preferred Qualifications
- Experience in healthcare, insurance, or managed care environments.
- Quality assurance, medical coding, or compliance certifications.
- Experience conducting audits and quality reviews in high-volume operational settings.
- Knowledge of regulatory and compliance requirements related to claims processing.
- Interested candidates are encouraged to apply and become part of a team committed to delivering accurate, compliant, and high-quality claims processing services.
Pay: ₹15,000.00 - ₹30,000.00 per month
Work Location: Remote
