Quality Auditor, Claims

**guard.me** International Insurance recognizes people as our most valuable asset. We look for individuals who like working with and helping people and who are interested in long-term career growth within an established, successful company. The work environment is fast-paced and high-energy. You'll have a chance to communicate with others, as everyone's input is valued. The culture is truly collaborative. You'll be working with an established award-winning team with an impressive track record.

If we still have your attention, please read through the responsibilities and qualifications and if you think you’re a good fit, we’d love to review your resume

**Responsibilities**:

- Learn, understand and maintain knowledge of **guard.me’s** policies and procedures
- Develop and manage a set of best practices, process and procedure for a robust and successful quality audit program.
- Complete assigned audits accurately and within a specific SLA’s.
- Monitor claims payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.
- Responsible for pre and post payment claim auditing of medical records and associated clinical documentation to ensure proper billing in accordance with standard billing policies and reimbursement principles.
- Complete and maintain detailed documentation of audits including but not limited to eligibility criteria, medical documentation, decision methodology, and monetary discrepancies identified.
- Coordinate with Claims Management and Training Specialist to identify gaps in claim integrity to ensure improvement and continuous learning for claims assistants and examiners.
- Recommend and assists in audit and documentation policy changes/new policies as necessary to ensure compliance, accurate billing, and sufficient documentation.
- Prepare written summaries and provide feedback on errors identified in the audit process; identify quality improvement opportunities and initiates remediation efforts when potential fraud, waste, usage and/or overpayment are identified.
- Liaise with Claims Management, Executive, internal or external teams as required.
- Coordinate overpayment recoveries with the Claims Manager.
- Participating in external audit requests, and special projects as needed.
- Prepare written reports and/or trending data related to findings and facilitates timely turnaround of audit results, including presentations
- Make recommendations for improvement of procedures, documentation, and revenue optimization opportunities.
- Coordinate, conduct, and document audits as needed for investigative purposes.
- Communicate effectively, both written and verbal, while ensuring privacy to peers, managers, clients and insureds.
- Maintain knowledge of healthcare conditions and developments.
- Such other duties and responsibilities as **guard.me** shall reasonably require.

**Qualifications**:

- Undergraduate degree in Business or Health Sciences
- A minimum of five (5) years in complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system.
- At least five (5) years of experience in managed health care environment related to claims processing/audit.
- An excellent communicator (spoken & written) with the ability to be compassionate in difficult medical situations.
- Highly organized, ability to multitask and adhere to timelines without compromising quality.
- Intermediate to Advanced knowledge of Microsoft Office (Outlook/Teams/Word/Excel), Adobe Reader, Internet Search Engines (Google Chrome, Mozilla, IE)
- Certified Professional Medical Auditor (CPMA); Certified Medical Auditor Reimbursement Specialist (CMARS); Certified Medical Audit Specialist (CMAS); Certified Healthcare Chart Auditor (CHCA), and/or any equivalent thereof would be beneficial.

Disclaimer: Please note that this document is intended to provide an overview of job accountabilities and does not necessarily list all tasks related to the job.

**How to Apply**:
**About Us**

**guard.me** is a leading provider of international student health insurance and, we’re so much more. That’s why, as a trusted partner for private and public universities, colleges, language schools and school boards, we created **guard.meCARES**, our innovative platform of health and wellness programs and services designed to mitigate risk, manage crisis events and improve health and wellness day-in and day-out.

**guard.meCARES** is more than a name; caring is at the heart of everything we do. It’s who we are and it’s why we are here. The philosophy of caring for students and our partners and giving back to the communities in which we do business is our guiding principle and what sets us apart from our competitors.

Our team of **Real People** delivers the personalized attention and culturally sensitive **Real Solutions** clients need for **Real Life. **We offer expert assistance during time