A Little More About this Role:
We’re looking for a Claims Quality Auditor to ensure medical claims are processed accurately and correctly in line with contractual requirements and regulatory standards. This role supports Gravie’s ability to get claims right the first time by proactively identifying problem areas, determining root causes, and closing any gaps or process compliance issues to prevent recurring issues.

You will:
– Conduct pre-payment, post-payment, and auto-adjudication audits, including routine to moderately complex claims covering multiple benefit plan designs.
– Ensure claims processing, payment, and financial accuracy by verifying that all required elements were handled correctly according to SPDs, regulatory requirements, and standard operating procedures.
– Track and report audit results in detail, including final decisions for reporting and trend analysis.
– Identify and recommend needed corrections and/or adjustments, and verify that they are completed accurately.
– Identify and escalate quality trends from reviews to support root-cause solutions, documentation improvements, and overall process enhancement.
– Investigate and research claim errors to create or improve standard processing guidelines.
– Serve as a subject-matter expert and/or partner with system SMEs to identify and report systemic issues that drive ongoing quality concerns.
– Participate in relevant cross-functional quality committees and working groups to communicate common quality issues, trends, and patterns.
– Support testing efforts for claims system upgrades, as needed.
– Participate in client external audits.
– Perform additional duties as required, including processing claims, creating policies, and training/mentoring examiners through quality improvement plans.
– Demonstrate a commitment to our core values: being authentic, curious, creative, empathetic, and outcome oriented.

You bring:
– A Bachelor’s Degree or equivalent work experience.
– 2 years of experience auditing medical claims for a health insurer or TPA.
– Extensive (5 years) medical claims processing experience.
– Ability to analyze data, recognize trends, and use the “5 Whys” approach to determine root cause.
– Strong knowledge of core system configuration.
– Ability to clearly explain findings and defend the methods used to reach them.
– Strong independent judgment, influence, and analytical skills.
– Excellent communication skills.
– Proven ability to achieve results through collaboration.

Extra credit:
– Experience at a startup company.
– Prior Payment Integrity experience.
– Coding certification from AAPC or AHIMA.
– Familiarity with Javelina claims processing software.

Gravie:
To build a more equitable and sustainable future for employer-sponsored health insurance, we need talented people delivering exceptional work. In return, we offer a strong overall employee experience, including opportunities for career growth, meaningful mission-driven work, and an above-average total rewards package.

The salary range for this role is $44,848–$61,130 per year. Compensation will be determined based on factors such as education, skills, work experience, certifications, and more.

Our benefits program is designed to be the “gravy”—the special sauce that sets our compensation apart. Along with standard health and wellness benefits, Gravie offers alternative medicine coverage, generous paid time off, up to 16 weeks paid parental leave, paid holidays, a 401k program, transportation perks, education reimbursement, and paid “paw-ternity” leave.

A Little More About Us:
We understand healthcare. Our company was founded and continues to be led by industry veterans who have built and grown multiple market-leading companies in the space.

We’ve received investment from top-tier investors who share our long-term vision of creating an industry-defining company that will last. We are well-capitalized.

Our clients value us highly. Employee satisfaction with Gravie health plans consistently ranks above 80%, nearly 40 points higher than the industry average.

Our culture is unique: we’re generally non-hierarchical, merit-based, and full of thoughtful, opinionated, yet kind people who thrive in a high-performance, fast-paced environment. We care deeply about making a positive impact in the lives of the people we serve. We may not be the right fit for everyone, but if you’re energized by doing work every day that puts consumers first, you could be a great match here. We believe unique people and diverse perspectives help us deliver results—so we encourage you to be your authentic self.

We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you’d like more information about how your data is processed, please contact us.