Claims Auditor

Responsibilities

• Perform auditing of claims (for internal and external constituents), ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client’s summary plan description.
• Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
• Communicate corrections and adjustments to Claims Adjustors as identified on pre-payment audits, including high-dollar claims, and verify corrections and adjustments are complete and accurate.
• Identify and escalate trends based on the quality reviews.
• Confer with Claims QA Lead, Claims Supervisors, Claim Managers, and/or Training Lead on any problematic issues warranting immediate corrective action.
• Investigate and research issues as required to create or improve standard processing guidelines and may participate in projects as a subject matter expert as needed.
• Perform any other additional tasks as necessary, including processing of claims, creating policies, training, and/or mentoring Claims Adjustors through quality improvement plans.

Qualifications

• Prior experience with a highly automated and integrated claims processing system, El Dorado-Javelina or Health Rules Payer (HRP) preferred.
• Detailed knowledge of relevant systems and proven understanding of processing principles, techniques, and guidelines.
• Strong analytical, organizational, and interpersonal skills, with the ability to communicate effectively with others.
• Attention to details, organized, quality and productivity driven.
• High School diploma or GED required. Associate or bachelor’s degree preferred.
• Minimum of three (3) years of experience as a claim adjustor and/or auditor with self-funded health care plans and processing in a TPA environment, meeting production and quality goals/ standards.
• Proficient experience in MS Word, Excel, Outlook, and PowerPoint required.