Claims Auditor

About Us

Assured Benefits Administrators, Inc. (ABA) is a full-service third-party administrator (TPA) providing flexible and fully integrated healthcare administration and management solutions across the United States since 1985. We are part of an international healthcare group with more than 35 years of industry experience and are fully integrated with our long-term partners, recognized as industry leaders. ABA is a certified “Great Place to Work,” united by a single mission: standing with members through every moment and milestone in their healthcare journey. With decades of industry experience and a team driven by passion, integrity, and excellence, ABA is committed to delivering connected, transparent, and innovative healthcare solutions to employers and members nationwide.

About the Role

The Claims Auditor is responsible for reviewing and auditing medical and dental claims to ensure accuracy, compliance with plan provisions, coding standards, and company policies. This role serves as a quality assurance resource by identifying processing errors, providing real-time feedback to claims processors, and ensuring high-dollar and complex claims are thoroughly reviewed prior to payment. The Claims Auditor also supports regulatory and internal audit requirements, including annual SOC audits, and contributes to continuous process improvement initiatives.

Responsibilities

• Audit medical and dental claims for accuracy, completeness, and compliance with benefit plans, company policies, and regulatory requirements.
• Review claims to verify proper coding, pricing, benefit calculations, and payment accuracy prior to adjudication or release.
• Examine claim forms, medical records, and support documentation to determine eligibility, coverage, and benefit payment.
• Review high-dollar claims to ensure all required documentation has been received and claims are accurately processed before release.
• Validate diagnosis codes and medical documentation to ensure claims meet stop-loss carrier requirements and identify any applicable exclusions.
• Analyze claims involving accidents, injuries, and other complex medical situations to ensure appropriate adjudication.
• Provide real-time feedback and guidance to Claims Processors to correct errors before claims are finalized.
• Monitor claim processing trends, identify recurring issues, and recommend training opportunities to improve quality and efficiency.
• Perform annual SOC audit reviews by selecting and auditing claims processed by each Claims Processor during the designated review period.
• Audit and release claims associated with year-end contract renewals and plan changes.
• Maintain detailed documentation of audit findings and communicate recommendations to management.
• Collaborate with Claims, Customer Service, Eligibility, and other departments to resolve claim issues and improve operational processes.
• Meet established departmental productivity, quality, and accuracy standards.
• Perform other duties and special projects as assigned.

Requirements

• Associate degree preferred; equivalent work experience will be considered.
• Minimum of three (3) years of experience in claims processing, adjudication, or claims auditing.
• Strong knowledge of medical terminology, insurance benefit administration, and healthcare claims processing is highly preferred.
• Working knowledge of ICD, CPT, and HCPCS coding principles preferred.
• Experience reviewing claims for coding accuracy, pricing, and benefit determination.
• Knowledge of stop-loss claim requirements is preferred.
• Strong analytical, organizational, and problem-solving skills.
• Excellent attention to detail and ability to identify discrepancies.
• Effective verbal and written communication skills.
• Proficiency with Microsoft Office applications and claims administration systems.
• Ability to prioritize workload and meet production and quality goals in a fast-paced environment.

Work Environment

The noise level in the work environment is usually low to moderate.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions.

• While performing the duties of this position, the employee is regularly required to talk or hear.
• The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls.
• The employee is occasionally required to stand; walk; sit; and reach with hands and arms.
• The employee must occasionally lift and/or move up to 25 pounds.
• Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus.