Claims Quality Auditor

About Gravie

Gravie is dedicated to delivering health benefit solutions that truly support small and midsize businesses and their employees. Our team, diverse and distinctive, is encouraged to bring their full authentic selves to work, fostering a collaborative and inclusive environment.

Role Overview

We are searching for a meticulous Claims Quality Auditor to verify the proper processing of medical claims, ensuring compliance with contract rules and relevant regulations. This position focuses on identifying and resolving inconsistencies and process gaps to enhance the accuracy of claims processed on the first attempt.

Key Responsibilities

• Perform audits prior to payment, after payment, and automated adjudications on routine to moderately complex claims across multiple benefit plans.
• Verify the accuracy of claim processing, payments, and financial records in line with Summary Plan Descriptions (SPDs), regulatory standards, and established procedures.
• Accurately document audit outcomes and decisions for reporting and trend analysis purposes.
• Pinpoint necessary corrections or adjustments and confirm their completion and accuracy.
• Detect recurring quality issues and contribute to root cause analysis, documentation improvements, and process enhancements.
• Investigate claim discrepancies to refine or develop standard processing protocols.
• Collaborate as a subject matter expert (SME) with system experts to address systemic quality challenges.
• Participate in cross-functional quality teams to communicate prevalent quality concerns and patterns.
• Support testing initiatives related to claim system upgrades when required.
• Assist in external client audits relating to claims.
• Undertake additional tasks such as claims processing, policy creation, and mentoring or training examiners aimed at quality improvement.
• Embody Gravie's core values: authenticity, curiosity, creativity, empathy, and a focus on outcomes.

Qualifications and Experience

• Bachelor's degree or equivalent professional experience.
• Minimum of 2 years auditing medical claims within a health insurance or Third Party Administrator (TPA) setting.
• At least 5 years experience in medical claims processing.
• Strong analytical skills to identify data trends and utilize root cause tools like the 5 Whys technique.
• Fundamental knowledge of core system configuration.
• Ability to clearly communicate audit findings and justify the evaluation methods used.
• Proven independent decision-making capabilities with strong influencing and analytical skills.
• Excellent verbal and written communication abilities.
• Track record of collaborative success in achieving desired results.

Preferred Qualifications

• Experience working in a startup environment.
• Background in Payment Integrity.
• Certification in medical coding from AAPC or AHIMA.
• Familiarity with Javelina claims processing software.

About the Company

• Founded and led by healthcare industry experts with a strong history of building leading companies.
• Well-funded by top-tier investors sharing a long-term vision for an influential and enduring company.
• Exceptional client satisfaction with employee health plan approval rates exceeding 80%, significantly above industry norms.
• A culture that values meritocracy, candidness balanced with kindness, and thrives in a high-energy fast-paced work environment.

Benefits

• Comprehensive health and wellness offerings including alternative medicine coverage.
• Flexible paid time off policies.
• Up to 16 weeks of paid parental leave.
• Paid holidays and a 401(k) retirement program.
• Commuter benefits and education reimbursement.
• Two days of paid leave for pet care (paw-ternity leave).