Medical Claims Auditor

Location:  Clearwater, FL


This Auditor position provides compliance evaluation of multiple support roles within the organization, including, but not limited to Member Provider Services, Clinical Support Staff, Care Advocate, Claims, Operations, and Credentialing. The Auditor conducts daily evaluation for compliance with contract and policy requirements of the function being evaluated. Position conducts evaluation and partners with quality and other department staffs for improvement change.

Essential Duties and Responsibilities:

  • Participates in design of monitoring formats and quality standards. Quality tools evaluate measureable, achievable goals based on policy and contract requirements of the function under evaluation.
  • Conducts monitoring / observation and documentation evaluation to assure adherence to established standards by program.
  • Provides quality scores based on program compliance evaluation daily, weekly and monthly results.
  • Utilizes databases to record and track all quality review information
  • Generates quality reports within established timeframes for the department as a whole
  • Provides trend data to management team  weekly, monthly and quarterly
  • Prepares and analyzes internal and external quality reports for management staff review
  • Provides feedback on individual and team quality scores
  • Reviews, updates, tracks and manages all procedural and training materials to ensure timely update of audit evaluation tools. 
  • Works collaboratively with department management to ensure accuracy of policy and training materials. Provides managers with notification of any changes to audit tools and metrics to validate compliance with element being audited.
  • Evaluates and maintains tracking logs on system, phone or external support structure failures that may impact service level adherence.
  • Participates in audit outcome and / or rebuttal meetings.  
  • Conducts analysis of data over time to trend improvements or identify continued areas of non-compliance. 
  • Escalates non-compliance trends to attention of V.P Quality Management
  • Embraces and continually supports Quality Management philosophy by being a catalyst for change and improvement
  • Conducts independent, unbiased, objective compliance evaluation. 
  • Ensures full understanding of process under evaluation for professional competency
  • Identifies individual, group and department training needs to achieve improvement
  • Meets or exceeds established auditor productivity and performance standards

Other Responsibilities:

  • Adheres to corporate and departmental policies and procedures.
  • Maintains strict confidentiality of client, company and personnel information
  • Demonstrates a strong commitment to the mission and values of the organization and quality department 
  • Adheres to company attendance standards
  • Performs other duties as assigned

Supervisory Responsibilities:  None


  • Strong organizational and interpersonal skills
  • Excellent written and verbal communication skills
  • Detail oriented
  • Ability to multi-task and work independently
  • Exceptional listening and analytical skills
  • Strong knowledge of  processes and techniques
  • Ability to apply and interpret basic quality / audit tools
  • Ability to develop basic quality / audit tools
  • Understands quality process concepts and importance of objective measurement


  • A minimum of three (3) years of experience in one or more of the functional areas being evaluated is preferred
  • Prior quality or auditing experience is preferred
  • Bilingual (English and Spanish) is preferred

Education and/or Experience:

A high school diploma is required, minimum of associate degree, or equal experience, preferred.

Certificates, Licenses, Registrations:

Professional quality certification such as Quality Auditor, Quality Improvement Associate, Quality Process Analyst, Quality Technician or lean process is preferred at time of hire. Will achieve minimum certification of Quality Improvement Associate within two years of hire date.

Computer Skills:

Proficiency using software programs such as MS Word, ACCESS, PowerPoint, Excel and Outlook

Environmental Factors/Physical Demands:

Work is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.

To apply, please forward resume to

Tell a friend