Claims Quality Audit Representative Jobs (NOW HIRING)

HealthEdge offers AI-powered operational infrastructure for health insurance companies, guaranteeing an enduring financial edge in an increasingly competitive market. We're experiencing strong market momentum, with a growing number of health plans choosing HealthEdge to modernize their operations and compete more effectively. As we expand, we're investing in the people who power that growth, making this a pivotal moment to join us and shape the future of healthcare technology. Learn more at HealthEdge.com.

UST HealthProof is a trusted partner for health plans, offering an integrated ecosystem for health plan operations that helps our customers achieve affordable, equitable health care for all. We have a strong global presence, with a workforce of over 4,000 people built on a foundation of simplicity, integrity, people-centricity, and leadership.

You Are

UST HealthProof is looking for a Quality Audit Team Lead, reporting to the Quality Audit Manager. The Quality Audit Team Lead is responsible for driving excellence in quality, productivity, and data-driven insights across a team of Claims and Enrollment Quality Auditors supporting Medicaid managed care, managed long-term care (MLTC), and dual-eligible (Medicare-Medicaid) lines of business. The Lead will oversee calibration efforts, provide coaching to auditors, and deliver actionable insights that strengthen both operational performance and audit quality. In addition, the Lead will partner with the leadership team and trainers to identify training opportunities.

The Opportunity

Calibration & Client Engagement

• Facilitate and lead client calibration calls to ensure alignment on audit scoring standards and expectations across claims and enrollment transaction types.
• Own UST HealthProof's Audit the Auditor program, ensuring consistent application of quality standards across the audit team.
• Partner with internal stakeholders and the client audit team to maintain consistent quality scoring practices.

Auditor Oversight & Productivity Tracking

• Monitor auditor productivity, ensuring audit volume and coverage targets are completed and tracked accurately across the claims and enrollment audit teams.
• Maintain audit completion compliance and escalate issues impacting productivity or coverage.
• Oversee the audit and rebuttal process, ensuring timely and consistent resolution of disputed findings.

Coaching & Quality Assurance

• Conduct side-by-side reviews and calibrations with Claims and Enrollment Quality Auditors to ensure consistent scoring practices.
• Deliver targeted coaching to auditors to reinforce accuracy, consistency, and development opportunities.
• Perform "quality on quality" reviews to validate the integrity of auditor scoring and reporting.

Reporting & Continuous Improvement

• Compile and present team and individual auditor QA performance, including inputs to management reporting such as the Monthly Performance Review (MPR).
• Compile and distribute monthly SLA reporting for claims and enrollment audit performance.
• Track remediation and corrective action plans resulting from audit findings through to closure.
• Support internal audit reporting and documentation requests, including audit trail and evidence support as needed.
• Identify trends and systemic issues through quality reviews and propose solutions to leadership.
• Partner with the Training team and operational Team Leads to close gaps in associate performance across claims, enrollment, and eligibility processing.
• Maintain currency on CMS and state Medicaid managed care rules, and managed long-term care (MLTC) and dual-eligible (D-SNP/MAP) guidelines relevant to the claims and enrollment audit scope.

What You Need

• 3+ years in health plan quality assurance, audit, or related health plan operations leadership environment.
• Health plan claims auditing experience required; enrollment/eligibility auditing experience strongly preferred.
• Medicaid managed care auditing experience preferred; managed long-term care (MLTC) or dual-eligible (Medicare-Medicaid) experience a plus.
• Strong analytical skills with the ability to interpret data and identify actionable trends.
• Proficiency in MS Excel, reporting tools, and quality monitoring platforms; familiarity with HealthRules Payor or GuidingCare preferred.
• Experience leading calibration sessions with clients and/or internal stakeholders.
• Strong organizational and time management skills, with the ability to manage multiple priorities simultaneously.
• Bachelor's degree in Business, Operations, Quality Management, or related field (or equivalent experience).
• Ability to analyze SLA and KPI data, report findings, and present them in a structured way to multiple levels of the organization.
• Capability to convey messages with understanding to multiple levels throughout the organization.
• Attention to detail and accuracy.
• Results-driven mindset.

For this role, we value:

• Strong problem-solving skills, with the ability to contribute to cross-functional, complex process improvement projects and lead limited-scope process improvement initiatives across the claims and enrollment audit teams. 

Geographic Responsibility:  Remote, US

Type of Employment: Full-time, permanent 

Work Environment: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job: 

• The employee is occasionally required to move around the office. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.  

• Work across multiple time zones in a hybrid or remote work environment. 

• Long periods of time sitting and/or standing in front of a computer using video technology. 

• May require travel dependent on company needs. 

The above statements are intended to describe the general nature and level of the job being performed by the individual(s) assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required. HealthEdge reserves the right to modify, add, or remove duties and to assign other duties as necessary. In addition, reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position in compliance with the Americans with Disabilities Act of 1990.  Candidates may be required to go through a pre-employment criminal background check. 

HealthEdge is an equal opportunity employer. We are committed to workforce diversity and actively encourage all qualified persons to seek employment with us, including, but not limited to, racial and ethnic minorities, women, veterans and persons with disabilities. 

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**The annual US base salary range for this position is $55,000 to $70,000. This salary range may cover multiple career levels at HealthEdge. Final compensation will bedeterminedduring the interview process and is based on a combination of factors including, but not limited to,your skills, experience,qualificationsand education.