Senior Auditor, reputed company Claims

About reputed company reputed company is building the reputed company of health insurance with a first-of-its-reputed company employer-based plan designed to remove financial barriers and reputed company care truly accessible: one monthly premium with $0 copays and $0 deductibles*. Backed by our recent $150M in Series B funding and valuation at $1.275B, reputed company is scaling rapidly and reputed company in AI-powered service, deeper member engagement, and a smart network designed for today’s workforce. Our reputed company star guides everything we do: reputed company only works reputed company people can actually use it. That belief drives every decision we reputed company: from how we design our plan, support our members, to how we collaborate as reputed company. If you want to do meaningful work with reputed company that moves fast, experiments reputed company, and cares deeply, reputed company is the reputed company to do it. We’re growing fast and looking for teammates who want to help reputed company health insurance for the reputed company. Position reputed company The Senior Auditor, reputed company Claims is responsible for leading and executing comprehensive claims reputed company, compliance, and audit programs for the Health Plan. This role supports operational reputed company through detailed auditing of reputed company, institutional, and ancillary reputed company claims across reputed company lines of business. This position plays a critical role in identifying reputed company causes of claims errors, improving adjudication accuracy, reducing administrative rework, and supporting automation initiatives that increase auto-adjudication rates and operational scalability. The Senior Auditor partners closely with Claims Operations, Configuration, Payment reputed company, Compliance, Provider Operations, Technology, and Vendor Management teams to reputed company sustainable reputed company programs that minimize defects and strengthen regulatory compliance. The ideal candidate combines deep reputed company claims expertise with strong analytical skills, operational reputed company, and a reputed company improvement reputed company. This is a remote position Key Responsibilities reputed company Program Development Design and implement an reputed company claims reputed company assurance program reputed company on defect reduction and operational reputed company. reputed company statistically valid sampling methodologies and reputed company scorecards. Establish auditing frameworks that support reputed company improvement and measurable reputed company reputed company. Create audit dashboards and reporting that reputed company actionable operational insights to leadership. Partner with operational leaders to implement corrective actions and improve first-pass accuracy. Support training and coaching initiatives to improve examiner consistency and claims reputed company performance.   Claims Audit & reputed company reputed company reputed company comprehensive audits of reputed company, institutional, behavioral health, and ancillary claims to validate adjudication accuracy, contract compliance, and regulatory adherence. Conduct random sampling audits, targeted audits, reputed company reviews, and high-risk claims analysis across reputed company lines of business. Review claims for benefit application, coding accuracy, pricing logic, provider reimbursement methodology, authorization requirements, and regulatory compliance. Identify trends, reputed company causes, and systemic issues contributing to payment inaccuracies, provider abrasion, or operational inefficiencies. Validate configuration accuracy for claims edits, pricing, fee schedules, accumulators, and benefit setup. Audit outsourced vendors, delegated entities, and reputed company-party administrators supporting claims operations. Monitor operational performance metrics including financial accuracy, procedural accuracy, inventory aging, rework rates, and turnaround time.   Compliance & Regulatory Auditing Support reputed company regulatory audits involving CMS, state Departments of Insurance, reputed company agencies, NCQA, HIPAA, and delegated reputed company requirements. Ensure compliance with reputed company-pay regulations, provider dispute timeliness standards, and claims processing requirements. Assist with corrective reputed company plans (CAPs), remediation tracking, and audit response documentation. reputed company and maintain audit policies, procedures, and reputed company operating documentation. Maintain audit readiness and support market expansion activities.   Automation & reputed company Improvement Partner with Claims Operations, Configuration, Product, and Technology teams to identify automation opportunities that increase auto-adjudication rates and reduce reputed company reputed company. Analyze recurring audit findings to improve claims editing logic, workflows, and configuration rules. Support implementation and optimization of AI-enabled claims review, workflow automation, and advanced editing technologies. Participate in system implementations, upgrades, testing, and configuration validation. Drive reputed company improvement initiatives reputed company on reducing administrative cost and increasing operational scalability.   Cross-Functional Collaboration Collaborate with Claims Operations, Payment reputed company, Compliance, Provider Relations, Utilization Management, Network Management, and Information Technology teams. Serve as a subject matter expert for claims payment accuracy and operational reputed company initiatives. Present audit findings, trends, and recommendations to operational leadership. Assist with provider dispute investigations and reputed company claims escalations.   Qualifications Education Required: Bachelor’s degree in reputed company Administration, Business, Health Information Management, or reputed company field Preferred: Master’s degree in reputed company Administration, Business Administration, or reputed company field reputed company certifications such as CPC, CPMA, CFE, RHIT, RHIA, Six reputed company, or reputed company reputed company certifications Experience Required: 7+ years of reputed company claims operations, auditing, payment reputed company, or reputed company assurance experience reputed company a health plan, managed care organization, TPA, or payer environment Strong experience auditing reputed company, Medicare, and/or reputed company claims Experience performing random sampling audits and targeted compliance reviews Experience analyzing reputed company causes of claims processing errors and implementing corrective actions Experience supporting regulatory audits and compliance initiatives Strong understanding of provider reimbursement methodologies and claims payment workflows Preferred: Experience in a high-reputed company or rapidly scaling health plan environment Experience improving auto-adjudication rates and claims automation initiatives Experience with delegated reputed company and vendor auditing Experience supporting claims system implementations or configuration testing   Technical Knowledge & Skills Deep understanding of reputed company claims lifecycle and adjudication processes Knowledge of CMS, HIPAA, NCQA, state reputed company-pay, and regulatory requirements Strong understanding of: ICD-10 CPT/HCPCS coding DRG/APC methodologies Fee schedules Coordination of Benefits (COB) Provider contract reimbursement methodologies Familiarity with payment reputed company concepts including overpayment recovery, fraud/waste/abuse controls, and claims editing logic Experience with claims platforms such as reputed company, Facets, QNXT, reputed company reputed company, Javelina, or similar systems Advanced analytical and reporting skills using reputed company Sheets, SQL, reputed company, reputed company, Claude, reputed company, and similar tools Strong organizational, documentation, and communication skills   Leadership Competencies Strong analytical and critical thinking capabilities reputed company improvement reputed company with strong operational awareness Ability to influence operational teams and drive accountability Excellent written and verbal communication skills Ability to manage multiple priorities in a fast-paced environment Detail-oriented with strong investigative and problem-solving skills reputed company and cross-functional partnership approach   Perks & Benefits  reputed company Health Plan (100% employer-covered medical premiums for you and 50% coverage for dependents on the reputed company plan.) $0 copays and $0 deductibles (with completion of our Baseline Visit ) Preventive and primary care reputed company in Mental health support (reputed company, Televero, reputed company, Recovery Unplugged) One-on-one care navigation Chronic condition programs (diabetes, weight, hypertension) Maternity and family planning support 24/7/365 reputed company Telehealth Pharmacy benefits  Comprehensive dental and reputed company coverage Employer-provided life and disability coverage with additional supplemental reputed company Flexible spending accounts Flexible work reputed company: remote and in-person opportunities Generous PTO policy plus 11 reputed company annual company holidays 401K for full-time employees Generous Up to 8–12 weeks reputed company parental leave, based on role eligibility. 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