Claims Auditor II

About the position

The Claims Auditor II is responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types, and products including specialized claims. This role requires working independently and without significant guidance. The primary duties include performing audits of high dollar claims while maintaining acceptable levels of claims inventory and age, ensuring claim payment accuracy by verifying various aspects of the claim such as eligibility, system coding and pricing, pre-authorization, and medical necessity. The auditor will also contact others to obtain necessary information, complete and maintain detailed documentation of audits, provide feedback on claims processing errors, identify quality improvement opportunities, and refer overpayment opportunities to the Recovery Team. Additionally, the auditor will independently interpret Medical Policy and Clinical Guidelines.

Responsibilities

• Performs audits of and may adjudicate high dollar claims while maintaining acceptable levels of claims inventory and age.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.
• Contacts others to obtain any necessary information.
• Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
• Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates basic and complex system requests related to coding or system issues.
• Refers overpayment opportunities to Recovery Team.
• Independently interprets Medical Policy and Clinical Guidelines.

Requirements

• Requires a HS diploma or GED
• Minimum of 5 years of claims processing experience including a minimum of 1 year related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.
• Working knowledge of insurance industry and medical terminology; detailed knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred.
• Strong research and problem solving skills preferred.

Benefits

• Compensation: $31.39/hr. - $47.09/hr. & bonus eligible