Claims Quality Auditor - Remote

Claims Quality Auditor| Remote

Job Type: Full time

Work Setup: Remote

Reports to: Claims Supervisor

Position Summary:

The Claims Quality Auditor plays a key role in ensuring the accuracy, compliance, and effectiveness of claims processing and provider dispute resolution. The ideal candidate has hands on experience with EZCap, auditing claims, analyzing dispute claims and evaluating internal policies and regulatory requirements, with a particular focus on Medi-Cal and commercial health plans. This role is responsible to partners closely with cross-functional teams to drive continuous improvement and operational excellence.

Key Duties:

• Perform detailed audits of denied, underpaid, and processed claims using EZCap to assess accuracy and compliance with provider contracts and regulatory guidelines.
• Analyze provider disputes for patterns or recurring issues.
• Identify root causes and work with relevant teams to implement corrective actions and process improvements.
• Develop and track performance related to claims accuracy, turnaround time, and dispute resolution efficiency.
• Conduct thorough root cause analyses on high-impact errors or escalations.
• Support training initiatives by identifying knowledge gaps and assisting in the development of updated procedures and documentation based on audit results.
• Ensure all reviewed processes align with applicable regulatory requirements. Participate in internal and external audits as needed.

Qualifications:

• High school diploma or equivalent
• At least 3-5 years of Quality Analyst in healthcare, TPA, or health plan settings/ healthcare claims or in a claims processing/adjudication environment
• Hands-on experience with EZCap (strongly preferred)
• Familiarity with Medi-Cal and Commercial insurance claim
• Strong analytical and problem-solving skills
• Excellent verbal and written communication
• Attention to detail in documentation and compliance
• Ability to manage multiple tasks and meet deadlines
• Experience with other claim adjudication platforms and provider systems.
• Familiarity with DHCS, DMHC, CMS dispute handling regulations.

What We Offer

• Remote work offered
• Equipment provided
• Paid training to set you up for success
• Comprehensive benefits: Medical, Dental, Vision, Life, HSA, 401(k)
• Paid Time Off (PTO)
• 7 paid holidays
• A supportive team and a company that values internal growth

COMPANY OVERVIEW:

Imagenet is a leading provider of back-office support technology and tech-enabled outsourced services to healthcare plans nationwide. Imagenet provides claims processing services, including digital transformation, claims adjudication and member and provider engagement services, acting as a mission-critical partner to these plans in enhancing engagement and satisfaction with plans' members and providers.


The company currently serves over 70 health plans, acting as a mission-critical partner to these plans in enhancing overall care, engagement and satisfaction with plans' members and providers. The company processes millions of claims and multiples of related structured and unstructured data elements within these claims annually. The company has also developed an innovative workflow technology platform, JetStreamTM, to help with traceability, governance and automation of claims operations for its clients.

Imagenet is headquartered in Tampa, operates 10 regional offices throughout the U.S. and has a wholly owned global delivery center in the Philippines.