Claims Auditor - TPA

About the role

The Claims Auditor ensures claims are processed in accordance with contractual, regulatory, and internal performance requirements. The individual in this role supports quality assurance efforts by auditing claims processing activity, documenting findings, and contributing to the continuous improvement of operational standards and compliance.

Responsibilities

• Performs operational and quality audits of claims processing activity to ensure accuracy, compliance, and adherence to contractual, regulatory, and internal guidelines.
• Reviews claims files, documentation, and processing workflows to confirm established procedures and standards are being followed.
• Documents audit results and prepares timely, accurate audit reports, findings, and supporting records.
• Tracks audit outcomes and identifies trends, recurring issues, or opportunities for improvement.
• Communicates audit findings to appropriate stakeholders and supports follow-up actions as directed.
• Actively participates in the development, review, and refinement of operational policies, procedures, and quality standards.
• Supports internal performance and compliance initiatives by providing data, insights, and documentation as needed.
• Facilitates collaboration and feedback across functional teams to promote consistent claims processing practices.
• Facilitates meetings related to audits, quality initiatives, or process improvements, as needed.
• Effectively utilizes available technology and tools, including emerging and AI-enabled solutions, to support efficient workflows, accuracy, and a positive client service experience.
• Special projects and other duties as assigned.

Requirements

• High school diploma or equivalent.
• Minimum 2 years of experience in claims processing and auditing.
• Demonstrated ability to review claims activity for accuracy, consistency, and compliance with established rules and guidelines.
• Strong attention to detail and analytical skills.
• Effective verbal and written communication skills.
• Ability to document findings clearly and maintain accurate records.
• Proficiency in Microsoft Word and Excel; ability to learn new systems and software applications.
• Ability to manage multiple priorities and meet deadlines in a structured environment.
• Commitment to confidentiality and appropriate handling of sensitive information.
• Consistently demonstrates professionalism, tact, and discretion.

Benefits

• Competitive pay.
• Family health and wellness programs.
• 401K.
• Employee assistance programs.
• Paid time off and paid holidays.
• Career advancement and development opportunities.

Pay

The wage range for this role is $23.00 - $33.65 per hour. This range takes into account factors such as skill sets, experience and training, licensure and certifications, and other business and organizational needs. You may also be eligible to participate in a discretionary annual incentive program, subject to the rules governing the program, where an award, if any, depends on various factors, including individual and organizational performance.