Job Description

As a Claims Auditor, you will be performing in-depth investigations of claims ensuring that accurate payments are being applied and proper processes are being used. Additionally, the Auditor will identify issues related to the documented processes and provide information to make improvements. The Auditor will be responsible for promptly identifying instances of under- and over-payment of accounts, submitting reports to management outlining inaccuracies in the payment process and ensuring that all health claim acceptances and denials are properly recorded by our financial team.

Responsibilities and Duties:

• 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 analyze 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 error trends, patterns and issues that require tool or process changes and report to management.
• Create service denial reports that ensure that all denials are being done within the guidelines provided.
• Maintain compliance, privacy and confidentiality in all documentation, communications, and correspondence.
• Review Underwriting documents prior to group renewal and provide feedback of any inconsistencies.
• Work with Implementation to ensure that the completed group documentation is signed and saved in the appropriate file.

Knowledge, Skills and Abilities:

• 3+ years working as a claim analyst/processor at a health insurance company
• Mastery of all types of claim processes
• Medical terminology, CPT, ICD, and Revenue Coding expertise
• Desire to grow and learn new skills
• Respected and trusted by peers and leaders
• Excellent interpersonal skills, desire to help others, strong communicator with internal and external parties who have varying knowledge and background, including translating complicated concepts, ensuring understanding, and building trust
• Proven team player who contributes to building high performing teams
• Self-starter who takes initiative, enjoys investigating and solving challenging problems, sees things through to completion and is highly accountable

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