Claims Auditor II
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About The Position
The Claims Auditor II is responsible for pre and post payment and adjudication audits of high dollar claims across multiple lines of business, claim types, and products including specialized claims. This role requires working independently and without significant guidance. The primary duties include performing audits of high dollar claims while maintaining acceptable levels of claims inventory and age, ensuring claim payment accuracy by verifying various aspects of the claim such as eligibility, system coding and pricing, pre-authorization, and medical necessity. The auditor will also contact others to obtain necessary information, complete and maintain detailed documentation of audits, provide feedback on claims processing errors, identify quality improvement opportunities, and refer overpayment opportunities to the Recovery Team. Additionally, the auditor will independently interpret Medical Policy and Clinical Guidelines.
