Claims Auditor I

Job Summary

The Claims Auditor is responsible for conducting comprehensive pre- and post-payment audits of claims processed by New Day Claim Examiners and Associates handling claim underpayment disputes. This role ensures payment accuracy, procedural compliance, and adherence to CMS Medicare guidelines within a managed care health plan environment. The auditor works independently to evaluate claims processing quality, identify discrepancies, and support continuous improvement initiatives.

Responsibilities

• Perform pre- and post-payment audits of claims, including high-dollar and complex claims, across Medicare managed care lines of business.
• Audit work completed by claim examiners and associates to ensure accuracy in underpayment dispute processing.
• Validate claim payment accuracy by reviewing:
  • Member eligibility
  • Coding (CPT, HCPCS, ICD)
  • Pricing and reimbursement methodologies
  • Authorization requirements
  • Medical necessity in accordance with CMS guidelines
• Ensure adherence to internal policies, CMS Medicare regulations, and clinical guidelines.
• Independently interpret medical policies, regulatory requirements, and reimbursement guidelines.
• Maintain acceptable audit inventory levels and turnaround times.
• Document audit findings in detail, including:
  • Decision rationale and methodology
  • Identified processing or system errors
  • Financial impact and discrepancies
• Produce audit reports used for:
  • Financial reconciliation
  • Trend analysis
  • Compliance reporting
• Track and trend audit outcomes to identify systemic issues and opportunities for improvement.
• Provide structured feedback and coaching insights to claim examiners and associates.
• Identify root causes of claim processing errors and recommend corrective actions.
• Partner with leadership and cross-functional teams to drive quality improvement initiatives.
• Initiate and support system enhancement requests related to coding, pricing, or workflow inefficiencies.
• Refer overpayment and recovery opportunities to the appropriate Recovery Team.
• Collaborate with internal departments (e.g., Clinical, Provider Relations, Compliance) to resolve complex claims issues.
• Contact providers or internal stakeholders to obtain necessary documentation or clarification.
• Serve as a subject matter expert (SME) on claims auditing standards and Medicare requirements.

Minimum Qualifications

• High School Diploma or GED required.
• Minimum of 5 years of claims processing experience, preferably within healthcare or insurance.
• At least 1 year of experience in a quality audit or claims auditing role.
• Experience with Medicare (CMS) guidelines and managed care environments strongly preferred.
• Equivalent combination of education and experience may be considered.

Preferred Qualifications

• Strong knowledge of:
  • Medical terminology
  • Claims processing systems
  • Coding methodologies (CPT, HCPCS, ICD-10)
• Proven understanding of claims adjudication principles, reimbursement methodologies, and audit techniques.
• Ability to interpret medical policies and clinical guidelines independently.
• Experience auditing underpayment disputes or payment integrity functions.

Skills & Competencies

• Strong analytical, research, and problem-solving skills
• High attention to detail and accuracy
• Ability to work independently in a production-driven environment
• Effective written and verbal communication skills
• Ability to manage multiple priorities and meet deadlines
• Proficiency in identifying trends and recommending process improvements