Claims Quality Auditor

Overview

This opportunity is for a Claims Quality Auditor in the United States, offered through a partner company that handles the application review and next steps. The role is centered on improving the accuracy, efficiency, and compliance of medical claims processing while helping uncover process gaps and root causes that affect quality.

You will combine claims auditing knowledge, analytical problem-solving, and cross-functional collaboration to strengthen operational performance, support compliance efforts, and contribute to continuous improvement. The position is suited to someone who enjoys working in a fast-moving, purpose-driven environment and wants to help improve the healthcare administration experience for members.

What you will do

In this position, you will review claims across multiple audit types, evaluate payment accuracy, and help ensure adherence to plan terms, regulations, and internal procedures. You will also document patterns, escalate issues, and support improvements that reduce repeat errors.

• Perform pre-payment, post-payment, and automated adjudication reviews for routine and moderately complex medical claims and benefit designs.
• Confirm that claims, payments, and related financial outcomes are correct based on plan documents, regulatory obligations, and operating procedures.
• Record audit outcomes, observations, trends, and quality metrics in a clear and structured way.
• Determine what corrections or adjustments are needed and follow through to ensure they are completed properly.
• Examine claim issues, trace the underlying causes, and suggest actions that help avoid repeated mistakes.
• Review quality trends and raise findings that can improve documentation, workflows, and operational practices.
• Work with system specialists and other teams to identify technology-related issues affecting claims quality.
• Take part in quality forums, external reviews, testing efforts, and process improvement work.
• Assist claims operations as needed through policy support, training, mentoring, and quality initiatives.
• Operate in a way that reflects the organization’s values of authenticity, curiosity, creativity, empathy, and measurable results.

Requirements

The ideal candidate should bring hands-on medical claims experience, previous auditing exposure, and the ability to interpret complex information and present findings clearly. Independent judgment, teamwork, and a continuous-improvement mindset are important for success.

• A bachelor’s degree or an equivalent combination of education and professional experience.
• At least 2 years of experience auditing medical claims in a health insurer or third-party administrator environment.
• Substantial medical claims processing background, generally around 5 years.
• Ability to examine data, spot trends, and use structured root-cause methods such as the 5 Whys.
• Understanding of claims system setup and day-to-day operational workflows.
• Ability to explain audit results clearly and describe how decisions were reached.
• Strong abilities in analysis, problem solving, decision making, and influencing others.
• Excellent written and spoken communication skills.
• Proven track record of working across teams to deliver results.

Preferred background

• Prior experience in a startup setting.
• Exposure to payment integrity work.
• Coding certification from AAPC, AHIMA, or a similar organization.
• Experience with Javelina claims processing software.

Compensation and benefits

The role includes a competitive hourly pay range of $22.04 to $29.39, with the exact rate depending on experience, skills, education, certifications, and other relevant factors. The package also includes a broad set of benefits designed to support wellbeing, development, and balance.

• Comprehensive health and wellness coverage.
• Coverage for alternative medicine.
• Generous paid time off.
• Up to 16 weeks of paid parental leave.
• Paid holidays.
• 401(k) retirement plan.
• Transportation benefits.
• Education reimbursement support.
• Paid paw-ternity leave.
• Career growth opportunities and meaningful work in a mission-driven environment.

Application and privacy information

This listing is managed through an AI-assisted matching process that reviews applications against the role’s core requirements and shares the strongest matches with the hiring company. Final hiring decisions, interviews, and assessments are handled by the employer’s internal team.

By applying, you acknowledge that your personal data may be processed to evaluate your candidacy and shared with the hiring employer where appropriate. The processing is described as being based on legitimate interest and pre-contractual measures under applicable data protection laws, including GDPR. You may request access, correction, deletion, or objection relating to your data at any time.

AI tools may also be used to support parts of the hiring workflow, including resume review, application analysis, and consistency checks. These tools assist recruitment staff but do not replace human judgment, and final hiring decisions are made by people.