Quality Auditor

Quality Auditor

The Quality Auditor is responsible for conducting internal audits and operational quality reviews to ensure accuracy, compliance, and consistency across operational functions. This role is primarily focused on claims auditing, with scope expanding to include customer service interactions and other operational workflows over time. The Quality Auditor applies critical thinking and sound judgment to evaluate transactions, identify trends, and make data-driven recommendations for performance improvement. This role ensures consistent application of audit standards and supports a culture of continuous improvement and operational excellence across the organization.

Duties and Responsibilities

• Conduct internal audits of healthcare claims transactions, reviewing for financial, procedural, and payment accuracy in accordance with established standards, plan agreements, and regulatory requirements.
• Expand audit scope over time to include customer service interactions, enrollment and billing transactions, and other operational workflows as assigned.
• Apply critical thinking and independent judgment to evaluate audit findings, determine root causes, and distinguish between isolated errors and systemic issues requiring escalation.
• Participate in and lead quality calibration sessions to ensure consistency in audit results and application of policies, procedures, and guidelines across the team.
• Document audit results accurately and completely in approved formats; maintain organized audit records and supporting documentation.
• Analyze audit data to identify trends, error patterns, and performance gaps; develop data-driven recommendations for process improvement and training needs.
• Assist with the identification and development of process gaps and deficiencies, including recommendations to support error resolution, best practices, and quality improvement initiatives.
• Conduct external vendor reviews as required and in alignment with vendor agreement standards.

Required Knowledge, Skills and Abilities

• HS Diploma or equivalent, Associates Degree preferred.
• 1+ years of audit experience in the Health Insurance Industry, including HIPAA and ERISA knowledge required.
• 1+ years healthcare claims and/or customer service experience.
• Bi-lingual Spanish preferred
• Ability to interpret, understand and apply policies, procedures and contract language (Client, Provider, Vendor, etc.)
• Solid working knowledge of standard computer applications including MS Word, Excel, Outlook and PowerPoint.
• Ability in using a computer which includes expert keyboard and navigation skills and learning new programs.
• Communicate clearly and professionally with internal and external customers.
• Work effectively as part of a team to achieve established outcomes. Understand other's roles and empower one another to take responsibility to be successful.
• Demonstrate a collaborative interaction with peers to reach a common goal as well as be a resource to team members and internal/external customers
• Pay close attention to detail in all aspects of the job
• Make decisions using available resources and sound judgment
• Maintain confidentiality and discretion
• Identify and resolve problems in a timely manner, gather and analyzes information skillfully
• Open to other's ideas and exhibits a willingness to try new things.
• Demonstrate accuracy and thoroughness; monitor work to ensure quality.
• Prioritize and plan work activities to use time efficiently.
• Adapt to changes in the work environment, manage competing demands and is able to deal with frequent change, delays, or unexpected events.
• Follows instructions, responds to direction, and solicits feedback to improve.
• Act in such a way to instill trust from management, other associates, as well as customers.

Physical and Cognitive Demands

• Constant: Talk, hear, speak, and use hands and fingers to operate a computer, telephone, keyboard/mouse; occasionally move about the office
• Constant: Visual ability such as close vision, distance vision, color and peripheral vision, depth perception and ability to adjust focus
• Occasional: Lift and/or move up to 10 pounds
• Constant: Regular, predictable attendance is required
• Constant: While performing the duties of this job, the employee is regularly sitting for the full shift.
• Constant: The cognitive skills needed to complete tasks include abilities such as learning, remembering, focusing, categorizing, and integrating information for decision making, problem-solving, and comprehending.

Work Environment

The physical environment is indoors in a controlled climate, office setting. The noise level may be low to moderate.