Claims QA Auditor - REMOTE

Company:  University of Massachusetts Medical School
Location: Shrewsbury
Hours: Full Time
Type: Permanent
Job Requirements / Description
Under the general direction of the Business Operations Manager, or designee, the Claims Quality Assurance Auditor (Auditor) is responsible for ensuring the integrity of invoice adjudication and outside medical payments in compliance with standard policies, procedures, and guidelines, as well as contractual agreements. The Auditor will verify the accuracy of medical pricing by ensuring accurate CPT, HCPC, ICD-10 and DRG coding.


The Auditor will interpret plan contract language and apply appropriate benefit coverages based on the contract provisions while meeting production and quality standards as defined by management. This role will track changes within contractual agreements and ensure that invoicing, claims adjudication, and payments are compliant with contract terms, as well as policy and procedures.


The Auditor will independently perform comprehensive audits of claims to source documents and identify inaccuracies. The Auditor will conduct quality audits of claims pre & post payment. The role requires research, problem resolution & specialized knowledge in the areas of contracts and Medicare regulations & reimbursement rules. The auditor will ensure timely intervention in order to enhance service delivery & client satisfaction. Performs business process assessments and makes recommendations in clear, concise summary format. Works independently to discern whether an issue needs internal escalation or direct client interface.

Conducts quality assurance audits for all lines of business to assess accuracy and consistency of claims processed.

Performs routine and random sampling audits of adjudicated claims to identify inaccurate claims adjudication.

Researches, trouble shoots and resolves errors in claims entry and processing.

Identifies and tracks changes in the claims adjudication system to ensure compliance with all contractual agreements and regulatory requirements, as well as to ensure efficiency and effectiveness of claims operations.

Ensures the payment system is updated with all contractual requirements.

Identifies prevalent trends for inaccurate claims processing and adjudication. This will include developing and presenting potential
solutions to management.

Works with claims leadership team to identify, develop and implement new or revised business processes and tools that will be used by staff to improve accuracy of claims operations.

Works to resolve difficult or complex claims, and recommends related training and staff development opportunities to improve claim payments and invoicing processes, resulting in maximization of revenue.

Tracks and monitors claims to identify potential missing charges, duplicate payments, reoccurring coding errors, rejected EDIs, accuracy of 835 and 837 processing. Takes independent action and recommends opportunities for improvement and resolutions to management.

Tracks and monitors processes to ensure all claims payments and invoicing are accurate and in compliance with payment terms.

Assists in the development of action plans to address quality deficiencies.

Builds productive working relationships internally and externally. Works closely with various functions such as finance, contracting and operations to ensure lines of communication are kept open with processing or auditing related issues.

Works with providers to correct any billing issues to improve the billing and invoicing processes.

Works to create complex analysis and reports, using Microsoft Excel, Microsoft Access and/or other systems as necessary and available.

Documents all policies and procedures and ensures all are updated timely.

Performs other related duties as assigned.

Bachelor's Level Degree, or commensurate years of experience in a directly related field



5-7 years of claims processing experience with a minimum of 3 years of claims auditing experience

Expertise with investigation, determination and reporting of claims processes

Expertise with identifying root cause claims adjudication process failures, ability to quantify program impact and present findings

Expertise with analyzing medical claims

Familiar with community based health care system medical systems and claims processing/adjudication processes

Demonstrated proficiency with principles and methodologies of process improvement. Apply these in the execution of responsibilities in support of a process focused approached

Demonstrated understanding and compliance with Medicare and HIPAA privacy requirements

Demonstrated ability to analyze data with judgment and discretion

Demonstrated organizational, interpersonal and problem-solving skills; Excellent oral and written communications skills

Demonstrated ability to handle details, multi-task, and prioritize work

Demonstrated proficiency with principles and methodologies of process improvement


Certified Professional Coder, CPC

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