Claims Auditor II

Horizon Healthcare Services•Newark, NJ

11h

About The Position

Performs audit samples on benefit coding, reimbursement, pricing, PIBA, and pharmacy to ensure accurate claim adjudication and reimbursement. The role independently reviews assigned audit samples across PG, LOS, LDLA, and FEP audit programs, covering claims, EDI, portal, inquiries, membership, and other operational work types. The auditor completes assigned volumes while meeting production, accuracy, quality, and documentation expectations; identifies and documents errors, variances, and noncompliant outcomes; and manages audit points through follow-up, validation, resolution, and closure. The position uses operational systems and the department audit tool, maintains audit-ready documentation, collaborates with business areas and internal colleagues, participates in calibration and knowledge-sharing, and escalates unclear or complex scenarios as appropriate. Other job-related duties, special assignments, and operational support activities may be assigned by management.

Requirements

High School Diploma or GED required.
3–5 years of claims processing experience required.
Systems knowledge, such as NASCO.

Responsibilities

Independently review assigned audit samples across PG, LOS, LDLA, and FEP audit programs, including claims, EDI, portal, inquiries, membership, and other operational work types, following established audit criteria and program-specific guidance.
Complete assigned audit volumes within production expectations while maintaining required accuracy, quality, and documentation standards.
Identify processing errors, variances, or noncompliant outcomes; cite findings as audit points; and document rationale and supporting evidence clearly and accurately.
Manage audit points through follow-up and resolution activities, including communication, validation, documentation updates, and closure within established timeframes.
Partner with business areas and internal team members to obtain clarification, confirm root-cause information, support audit-point resolution, and ensure findings are addressed appropriately.
Use applicable systems and tools to complete audit work and document results.
Maintain complete, accurate, and organized audit documentation to support findings, audit-point activity, re-review, reporting, and audit readiness.
Participate in calibration activities, share knowledge, and assist with onboarding or guidance for less experienced auditors as appropriate.
Escalate unclear, conflicting, or complex scenarios to senior auditors or management, as appropriate.
Perform other job-related duties, special assignments, and operational support activities assigned by management to meet departmental, regulatory, and business needs.