Claims Auditor II

Horizon Blue Cross Blue Shield of New Jersey•Newark, NJ

21h•$63,000 - $84,420

About The Position

The Claims Auditor II performs audit samples on benefit coding, reimbursement, pricing, PIBA, and pharmacy to ensure accurate claim adjudication and reimbursement. The role independently reviews assigned samples across PG, LOS, LDLA, and FEP audit programs, completes audit volumes to established production, accuracy, quality, and documentation standards, and manages identified audit points through follow-up and resolution. The auditor works with business areas and internal team members, uses operational systems and the department audit tool, and helps maintain consistent audit practices. This role also supports related assignments and operational needs as directed by management. Horizon Blue Cross Blue Shield of New Jersey describes itself as a mission-driven organization focused on improving health care quality, affordability, and member experience. Employees in this position must live in New Jersey, New York, Pennsylvania, Connecticut, or Delaware.

Requirements

High school diploma or GED.
3–5 years of claims processing experience.
Systems knowledge, such as NASCO.

Responsibilities

Independently review 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 established production expectations while meeting accuracy, quality, and documentation standards.
Identify processing errors, variances, or noncompliant outcomes; cite findings as audit points; and document rationale and supporting evidence.
Manage audit points through follow-up and resolution, including communication, validation, documentation updates, and timely closure.
Partner with business areas and internal team members to obtain clarification, confirm root-cause information, support resolution, and ensure findings are addressed appropriately.
Use applicable systems and tools to conduct audits and document results, including NASCO, Blue Squared, Local, BlueCard, other operational systems, and the department’s audit tool.
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 as assigned by management.