• Supervisor Quality Auditing

    AmeriHealth Caritas (Philadelphia, PA)


    Job Summary:

    The Quality Auditing Team Lead oversees day‑to‑day operations of the Quality Auditing department with a strong focus on **claims auditing** accuracy, compliance, and process integrity. This role manages multiple audit types—including Claims Performance, Compliance, and Operational audits—to ensure adherence to regulatory, contractual, and internal quality standards across AmeriHealth Caritas. The position also supports special projects and analytical initiatives that drive continuous improvement in claims processing and quality outcomes.

    Key Responsibilities

    + Lead and manage claims-focused audits, including Performance Management, Compliance, Enterprise Operations, Pre‑Production, and Targeted claims audits.

    + Apply comprehensive knowledge of claims processing rules, benefit structures, business policies, and regulatory requirements across multiple lines of business; clearly communicate audit findings and trends.

    + Oversee the Quality Auditing appeals process, including documentation, tracking, claims-related decision review, and resolution guidance.

    + Develop, update, and implement audit protocols, claims auditing procedures, and operational strategies to enhance accuracy and consistency.

    + Identify system, workflow, or operational issues impacting claims quality performance; provide detailed analysis and actionable recommendations.

    + Coordinate claims audit inventory, assignments, and special projects to ensure timely and accurate completion.

    + Coach and mentor team members to improve claims auditing accuracy, documentation quality, and overall performance.

    + Represent the Quality Auditing department in cross‑functional meetings related to claims operations, quality initiatives, and enterprise projects.

    + Respond professionally to inquiries related to claims audits, appeals, and special project evaluations.

    + Maintain thorough and compliant audit documentation and records in alignment with retention policies.

    + Report content or system issues impacting claims auditing tools and platforms (e.g., Online Help, Facets, IAD).

    Education & Experience

    + Bachelor’s Degree or equivalent experience.

    + Minimum 1 year of internal quality/claims auditing experience.

    + Minimum 3 years of healthcare or claims operations experience.

    + Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint); Access preferred.

    Skills & Abilities

    + Strong analytical and problem‑solving skills, with emphasis on claims data review and error identification.

    + Excellent communication, leadership, and collaboration skills, especially in cross‑functional claims environments.

     

    Our Comprehensive Benefits Package

     

    Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

     

    **Why Join Us:** Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you are driven to make a difference, we want to hear from you.

     

    About AmeriHealth Caritas

     

    Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at http://www.amerihealthcaritas.com

    As a company, we support internal diversity through:

    Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.