Quality Auditor – Health Plan Operations

SCAN

Quality Auditor performing audits across health plan operations at SCAN. Ensuring compliance with regulatory requirements and operational standards, enhancing member and provider experience.

Posted 7/29/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $25 - $37 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in regulatory compliance and auditing processes within healthcare, specifically in Claims, Grievances and Appeals, Enrollment, and Provider Data. Proficient in utilizing analytical skills and effective communication to enhance operational efficiency and customer service.

Highest-signal resume keywords

Claims ProcessingGrievances And AppealsMedicare And Medicaid AuditingCMS Requirements KnowledgeHealth Insurance Training

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Auditing ExperienceRegulatory ComplianceAnalytical ThinkingOrganizational SkillsMedical Terminology Knowledge

Soft Skills

Oral CommunicationWritten CommunicationCollaborationProblem-Solving

Tools & Technologies

Microsoft OfficeExcelWordOutlookTeams

Industry Keywords

Managed CareHealthcareClaimsEnrollmentProvider Data

About the role

Key responsibilities & impact

Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials standards for assigned business process.
Work assigned cases through SCAN’s workflow system, and applies correct status attributes to track and trend issues.
Notate cases/audits with required detail to ensure that others understand status of case/audit and final resolutions.
Work closely with other business units to ensure processing errors are reviewed and corrected.
Follow policies and procedures in order to maintain efficient and compliant operations; communicate suggestions for improvement and efficiencies to management; identify and report problems with workflows following proper departmental procedures; actively participate in departmental staff meetings and training sessions.
Follow all appropriate Federal and State regulatory requirements and guidelines applicable to SCAN Health Plan operations or as documented in company policies and procedures.
Provide a high level of customer service to internal customers by consistently meeting and/or exceeding team expectations including but not limited to quality, productivity and attendance.
Escalate appropriate audit issues to management as required and follow departmental/organizational policies and procedures.
Maintain required levels of production and quality standards as established by management.
Participate in and supports ad-hoc audits as needed.
Contribute to overall department success by participating in department initiatives, effective communication and collaboration with all members of the SCAN team through knowledge and idea sharing, take ownership to identify and report issues to appropriate management staff for resolution and work actively with the SCAN team to improve the support to our Members and Providers.
Contribute to team effort by accomplishing related results as needed.
Actively support the achievement of SCAN’s Vision and Goals.

Requirements

What you’ll need

Associate’s degree preferred or equivalent experience
3+ years complex auditing processing and/or auditing experience in the health plan, healthcare, or managed care organization with experience in Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and/or Letters/Materials.
Must be proficient in processing/auditing for Medicare and Medicaid plans.
3+ years’ experience in managed healthcare environment related to Claims, Grievances and Appeals, Enrollment, Configuration, Provider Data and Letters/Materials processing/audit processing/audit.
Strong organizational, analytical thinking and accounting skills; oral and written communication skills.
Strong knowledge of CMS requirements regarding auditing processing.
Completion of health insurance training and medical terminology or equivalent knowledge through on-the-job training and experience.
Knowledge of health care benefit structures and insurance procedures, as they exist in a Managed Care environment.
Strong PC Skills. Microsoft Office (Word, Excel, Outlook, Teams) are required.

Benefits

Comp & perks

Annual bonus program
Robust Wellness Program
Generous paid-time-off (PTO)
Eleven paid holidays per year, plus 1 additional floating holiday, plus 1 birthday holiday
Excellent 401(k) Retirement Saving Plan with employer match and contribution
Robust employee recognition program
Tuition reimbursement