Claims Auditor

National Healthcare Solutions Group•El Paso, TX

9d•Onsite

About The Position

The Claims Auditor is responsible for reviewing and auditing medical and dental claims to ensure accuracy, compliance with plan provisions, coding standards, and company policies. This role serves as a quality assurance resource by identifying processing errors, providing real-time feedback to claims processors, and ensuring high-dollar and complex claims are thoroughly reviewed prior to payment. The Claims Auditor also supports regulatory and internal audit requirements, including annual SOC audits, and contributes to continuous process improvement initiatives.

Requirements

Minimum of three (3) years of experience in claims processing, adjudication, or claims auditing.
Strong knowledge of medical terminology, insurance benefit administration, and healthcare claims processing is highly preferred.
Working knowledge of ICD, CPT, and HCPCS coding principles preferred.
Experience reviewing claims for coding accuracy, pricing, and benefit determination.
Knowledge of stop-loss claim requirements is preferred.
Strong analytical, organizational, and problem-solving skills.
Excellent attention to detail and ability to identify discrepancies.
Effective verbal and written communication skills.
Proficiency with Microsoft Office applications and claims administration systems.
Ability to prioritize workload and meet production and quality goals in a fast-paced environment.

Nice To Haves

Associate degree preferred

Responsibilities

Audit medical and dental claims for accuracy, completeness, and compliance with benefit plans, company policies, and regulatory requirements.
Review claims to verify proper coding, pricing, benefit calculations, and payment accuracy prior to adjudication or release.
Examine claim forms, medical records, and support documentation to determine eligibility, coverage, and benefit payment.
Review high dollar claims to ensure all required documentation has been received and claims are accurately processed before release.
Validate diagnosis codes and medical documentation to ensure claims meet stop-loss carrier requirements and identify any applicable exclusions.
Analyze claims involving accidents, injuries, and other complex medical situations to ensure appropriate adjudication.
Provide real-time feedback and guidance to Claims Processors to correct errors before claims are finalized.
Monitor claim processing trends, identify recurring issues, and recommend training opportunities to improve quality and efficiency.
Perform annual SOC audit reviews by selecting and auditing claims processed by each Claims Processor during the designated review period.
Audit and release claims associated with year-end contract renewals and plan changes.
Maintain detailed documentation of audit findings and communicate recommendations to management.
Collaborate with Claims, Customer Service, Eligibility, and other departments to resolve claim issues and improve operational processes.
Meet established departmental productivity, quality, and accuracy standards.
Perform other duties and special projects as assigned.
May perform other duties as required.