Claims Audit Specialist

Welbehealth Non Sponsored Board

About The Position

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what. The Claims Audit Specialist is accountable for ensuring the timely and accurate payment or denial of claims while meeting federal/state regulations, provider agreement terms, and company policies and procedures. This role requires a strong knowledge of health plan operations, including the proper processing of professional, institutional, and dental claims, coding, CMS/Medi-Cal regulations, and in-depth comprehension of provider contracts and agreements. The Claims Audit Specialist collaborates effectively with Plan Operations leadership to identify trends that require escalation and training needs, and suggest process improvements. This role is different because the Claims Audit Specialist at WelbeHealth: Ensures accuracy and compliance by auditing complex Medicare and Medi-Cal claims, directly impacting financial integrity, regulatory adherence, and provider trust Plays a key role in identifying trends, mitigating risk, and driving process improvements across claims operations, helping strengthen overall system performance and reduce errors

Requirements

Bachelor’s degree in relevant field; professional experience may be substituted
Minimum of five (5) years of experience processing, researching, adjusting, and auditing Medicare and Medicaid professional, institutional, and dental health insurance claims
Experience processing and auditing disputes, appeals and recoveries
Proficient experience in Microsoft Excel
Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations
Experience working with CMS and Medi-Cal healthcare claims
Strong organizational, analytical, communication, and time management skills

Responsibilities

Review processed claims for pre and post payment accuracy while maintaining acceptable levels of aged claims inventory
Ensure claim payment accuracy by verifying various aspects of the claim form, including but not limited to participant eligibility, system configuration, payment accuracy or denial appropriateness, provider records, remark codes, pre-authorization requirements, timely filing limitations, claim history, and W9 receipt
Maintain detailed documentation of audit findings, including decision methodology, system configuration or manual processing errors, and monetary discrepancies
Regularly provide feedback to the Oversight & Monitoring Manager on claims processing errors, as well as identify quality improvement opportunities and initiate configuration change requests when applicable
Accurately process and release high dollar/stop loss claims exceeding $10k
Participate in annual claims audits to cure any deficiencies in claims system, human error, or possible fraud, waste, and abuse in order to maintain contractual and regulatory compliance
Act as a back up to the Claims team as needed