Quality Auditor in United States at Jobgether

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Quality Auditor in United States.

This role plays a critical part in ensuring the accuracy, compliance, and consistency of health plan claims processing within a regulated healthcare environment. You will be responsible for auditing operational transactions performed by claims administration teams, helping maintain high standards of quality and adherence to contractual and regulatory requirements. The position requires strong analytical ability and attention to detail to identify errors, trends, and opportunities for process improvement. You will collaborate closely with operations, training, and leadership teams to provide actionable feedback and strengthen overall performance. The role is highly structured yet collaborative, offering exposure to CMS guidelines and health plan audit frameworks. It is well suited for professionals who enjoy working with data, compliance standards, and continuous improvement in a remote healthcare operations setting.

• Perform detailed audits of health plan claims transactions processed by operations teams to ensure accuracy and compliance with established guidelines.
• Apply customer-specific quality processes and tools to manage audit execution, reporting, and rebuttal workflows.
• Analyze audit findings and share clear, structured feedback with individual associates and operational leaders to drive performance improvement.
• Compile and report QA metrics at both individual and team levels, supporting management visibility into quality trends and outcomes.
• Support training and operational teams by identifying recurring issues, process gaps, and refresher training needs.
• Participate in calibration sessions to ensure consistency and alignment in audit practices and scoring methodologies.
• Maintain up-to-date knowledge of CMS guidelines and regulatory requirements for Medicare Advantage and ACA-related lines of business.
• Collaborate cross-functionally in a remote environment to ensure consistent application of quality standards across teams.

• High school diploma or GED required.
• 3+ years of experience in health plan claims administration and auditing operations.
• Medicare claims auditing experience strongly preferred.
• Strong understanding of healthcare claims processes, contractual SLAs, and performance KPIs.
• Proficiency in Microsoft Office Suite, especially Excel, PowerPoint, and Outlook.
• Experience with platforms such as HealthRules Payor or GuidingCare preferred.
• Strong analytical and problem-solving skills with high attention to detail.
• Excellent written and verbal communication skills with the ability to provide clear, constructive feedback.
• Ability to work effectively in a remote, multi-time-zone team environment.
• Strong organizational skills and ability to manage multiple audit tasks simultaneously.
• Comfortable working in a regulated, compliance-driven healthcare environment.

• Competitive annual salary ranging from $35,000 to $48,000 depending on experience and qualifications.
• Full-time permanent remote position with geographic flexibility across the United States.
• Opportunity to work within a leading healthcare technology and services environment.
• Exposure to Medicare Advantage, ACA, and complex health plan claims operations.
• Professional growth opportunities through training, calibration sessions, and cross-functional collaboration.
• Standard corporate benefits package (details vary by eligibility and location).
• Collaborative and structured work environment focused on quality and continuous improvement.
• Reasonable accommodations available in accordance with applicable disability laws.