Claims Audit Analyst

Worldwide Insurance Services•King of Prussia, PA

3d•$0 - $52,073•Hybrid

About The Position

The Claims Audit Analyst evaluates health insurance claims and operational work to ensure accuracy, consistency, and compliance with benefit provisions, company policies, client requirements, and regulatory guidelines. The role conducts routine, random, and high-dollar claim audits; maintains audit schedules and documentation; and supports client-specific audit requirements across business lines. The analyst compiles audit findings, prepares monthly quality reports, analyzes trends and operational risks, and recommends improvements. The role also supports internal and external audits, reviews quality-control processes and related documentation, responds to stakeholder inquiries, and partners with operational teams on clarifying findings and corrective actions. The analyst contributes to quality initiatives, training, performance development, and a culture of accountability and operational excellence.

Requirements

High school diploma or equivalent.
At least 5 years of experience in health insurance claims examination, adjudication, or related healthcare operations roles.
Strong knowledge of medical claims processing, benefit structures, and insurance terminology.
Understanding of CPT, ICD-10, and healthcare reimbursement concepts.
Strong analytical, problem-solving, and decision-making abilities.
Excellent written and verbal communication skills.
Ability to interpret policies, identify exceptions, and document audit findings.
Proficiency with Microsoft Office and comfort working within claims administration systems.
Ability to manage multiple priorities while maintaining accuracy and objectivity.

Nice To Haves

Additional education or certifications.
Experience performing claims quality audits.
CPC, CCS, or other coding certifications.
Experience supporting Federal Employee Program (FEP) audits.
Knowledge of BCBS Association audit requirements.
Experience creating audit reports, scorecards, or trend analyses.
Experience presenting findings and recommendations to leadership.
Experience working in a highly regulated healthcare environment.

Responsibilities

Conduct quality audits of claims that exceed processor payment authority levels.
Perform routine and random audits of claim processing to assess compliance with company policies, client requirements, and regulatory guidelines.
Review claims adjudication decisions for accuracy, consistency, and adherence to benefit provisions.
Evaluate work completed by Claims Analysts, Claims Adjusters, Payment Specialists, and other operational team members.
Maintain audit schedules and complete required audit volumes within established timeframes.
Support client-specific auditing requirements for Classic, BCBS Global Core, FEP, and other assigned business lines.
Compile audit findings and maintain accurate audit documentation.
Prepare monthly audit statistics and quality performance reports for leadership.
Analyze audit results to identify trends, recurring issues, training opportunities, and operational risks.
Provide recommendations to improve quality, consistency, and efficiency.
Support internal and external audit initiatives, including Association and client audits.
Review surcharge reports, approval queues, and other quality-control processes as assigned.
Complete high-dollar claim notifications, stop-loss filings, and related documentation.
Respond to audit-related inquiries and requests from internal stakeholders.
Ensure claims processing activities align with client requirements, company standards, and applicable regulations.
Partner with operational teams to clarify findings and support corrective action planning.
Assist with departmental quality initiatives and continuous improvement efforts.
Share audit insights and best practices to improve claims accuracy.
Collaborate with leadership on training and performance development programs.
Promote a culture of quality, accountability, and operational excellence.
Support additional projects and responsibilities as assigned.