Auditor Claims BCI

Highmark Health•Carolina, PA

About The Position

The Auditor Claims position at Highmark Inc. is responsible for ensuring all claims are handled according to internal procedures and plan wording. This role involves monitoring audit workflows for timely turnaround, maintaining quality and production standards, and recording results for monthly reporting. The position also includes partnering with supervisors on training, conducting one-on-one coaching with the claims team, and providing recommendations for dollar authorization. Additionally, the Auditor Claims will assist with specialized audits, maintain knowledge of benefits and regulations, review complex claim situations, and utilize communication skills to liaise with various stakeholders. The role also manages refund, void, and stop payment processes, provides guidance on claims processing, and assists with system upgrade testing.

Requirements

HS/GED: Required
5 years prior medical dental, vision, FSA and HRA claims processing experience.
Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding
Strong attention to details along with organizational skills
Excellent problem solving with the ability to work in a fast paced production environment
Excellent communication skills both verbal and written
PC navigation skills for Professional work environment
Basic MS Excel
Basic MS Word
Ability to use judgement to make sound decisions referencing all available resources
Ability to work independently and also as part of a team
Problem Solving Ability to research and seek assistance through all available resources, to ensure resolution on claim audits.
Must be able to multi-task and follow up at appropriate intervals.
Raise concerns to the management team on situations and/or issues in a timely manner.

Nice To Haves

Associate Degree

Responsibilities

Ensure all claims are handled according to all internal operating and administrative procedures along with reviewing plan wording for each individual employer group, which should include the plan document, amendments, matrices and benefit summary.
Monitor workflow of audits to ensure timely turnaround time. Identify the performance guarantee group’s audits to meet the strict guidelines for turnaround time.
Maintain workload in accordance with the quality and production standards defined for the auditing team.
Record results in the audit tool for monthly reporting. Partner with the supervisor to create and conduct training sessions for issues identified by the management team.
Conduct one on one coaching with the claims team especially the trainee staff.
Provide recommendation for dollar authorization for claims team members based on audit stats and interaction with individual claim team members.
Assist supervisor with specialized audits for the SOC process, carrier, vendor and employer audits as necessary.
Maintain detailed knowledge of benefits, state regulations, federal guidelines and system upgrades.
Review and provide expertise to the claims team with complex claim situation/issues by using all resources to render a sound decision.
Utilize excellent written or verbal communication skills to liaise with clients, management, peers and other areas within the organization.
Manage the refund, void and stop payment process.
Provide guidance to the claims team with questions on all aspects of claims processing.
Assist with system upgrade testing.