Quality Auditor - Insurance/Healthcare

Job Description :

- Monitors daily claims activity to identify any instances where contractual obligations were violated or where the facility under or over-performed based on contract requirements.

- Use the existing auditing platforms to analyse claims and ensure that the proper amount of funds was applied to each claim.

- Work with Compliance Manager to ensure that each claim is being billed and administered in accordance with health insurance requirements and legal framework.

- Identify persistent claims error trends and report those trends immediately to management.

- Create service denial reports that ensure that all denials are being done within the guidelines provided.

- Perform and control the full audit cycle including risk management and control management over operations' effectiveness, financial reliability and compliance with all applicable directives and regulations.

- Determine internal audit scope and develop annual plans.

- Obtain, analyse and evaluate accounting documentation, previous reports, data, flowcharts etc.

- Prepare and present reports that reflect audit's results and document process.

- Act as an objective source of independent advice to ensure validity, legality, and goal achievement.

- Identify loopholes and recommend risk aversion measures and cost savings.

- Maintain open communication with management and audit committee.

- Document process and prepare audit findings memorandum.

- Conduct follow up audits to monitor management's interventions.

- Engage to continuous knowledge development regarding sector's rules, regulations, best practices, tools, techniques, and performance standards.

Qualifications :

- Degree or equivalent experience in a relevant field.

- 5 to 8 years of relevant experience in Quality Assurance within the Contact Centre industry, preferably in a Fortune 100 company.

- Strong domain expertise in industries such as Insurance, Healthcare, or Utilization Management, with a solid understanding of relevant regulations and guidelines.

- Excellent analytical skills to analyse customer interactions, keywords, identify trends, patterns, and areas of improvement, and provide data-driven recommendations.

- Ability to work independently and collaboratively in a fast-paced environment and manage multiple tasks and priorities effectively.

- Professional certifications related to Quality Assurance, Contact Centre, or relevant domain (e.g. Six Sigma, COPC, HIPAA) are a plus.