Claims Quality Auditor

HealthEdge

. Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates.

Posted 10/30/2026full-timeRemote • United StatesMid-LevelSenior💰 $44,000 - $58,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Medicaid managed care enrollment auditing, including dual-eligible Medicare-Medicaid coordination and compliance with CMS guidelines. Proficient in analyzing enrollment transactions and providing actionable feedback to enhance team performance.

Highest-signal resume keywords

Medicaid Managed Care Enrollment AuditingDual-Eligible Medicare-Medicaid CoordinationEDI 834 Enrollment TransactionsMS Suite ProficiencyHealthRules® Payor Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Enrollment AuditingEligibility VerificationData AnalysisQuality Assurance ReportingContractual SLA Analysis

Soft Skills

Effective CommunicationCollaborationFeedback Coordination

Tools & Technologies

MS ExcelMS PowerPointMS OutlookGuidingCare®

Industry Keywords

CMS GuidelinesMedicaid Enrollment RequirementsManaged Long-Term Care (MLTC)Audit the Auditor ProgramEnrollment Processing Timeliness

About the role

Key responsibilities & impact

Perform audits of enrollment, disenrollment, eligibility, and plan/PCP change transactions processed by health plan enrollment associates.
Follow the customer quality process and tools for audit and rebuttal processes.
Review enrollment (834) file transactions and coordinate with state enrollment systems and enrollment brokers to confirm member effective dates, retroactive enrollment/disenrollment, and eligibility segments.
Verify timely and accurate Medicaid eligibility redeterminations and recertifications against CMS and state Medicaid timeliness standards.
Audit dual-eligible Medicare-Medicaid enrollment coordination, including Medicare and Medicaid eligibility segments and coordination of benefits.
Share QA results with associates and coordinate with Team Leads and managers to provide feedback and identify errors and improvement opportunities.
Compile and report team and individual QA performance to management and associates.
Provide input to Training and Team Leads for processing instructions and refresher training needs.
Participate in the Audit the Auditor program.
Participate in semi-annual or annual auditor calibration activities.
Maintain current knowledge of CMS Medicaid managed care enrollment guidelines, state Medicaid enrollment requirements, and MLTC enrollment/disenrollment rules.
Report to the Lead Auditor or Quality Audit Manager and interact daily with client audit teams and operational managers.

Requirements

What you’ll need

High School Diploma or GED required.
3 years health plan enrollment/eligibility auditing operations experience required.
Medicaid managed care enrollment auditing experience preferred.
Managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) enrollment experience strongly preferred.
Proficiency in using MS Suite, specifically Excel, PowerPoint and Outlook.
HealthRules® Payor or GuidingCare® experience preferred.
Familiarity with EDI 834 enrollment transactions and eligibility verification systems a plus.
Ability to analyze contractual SLAs and KPIs, particularly around enrollment processing timeliness.
Ability to effectively communicate and collaborate with a remote team.
Candidates may be required to go through a pre-employment criminal background check.

Benefits

Comp & perks

Remote work environment
May require travel dependent on company needs
Reasonable accommodations for individuals with disabilities
Equal opportunity and workforce diversity commitment