Claims Auditor

National Healthcare Solutions Group LLC•El Paso, TX

1d•Onsite

About The Position

Assured Benefits Administrators, Inc. (ABA) is a full-service third-party administrator, or TPA, providing flexible and fully integrated healthcare administration and management solutions across the United States since 1985. We are part of an international healthcare group with more than 35 years of industry experience, and we’re fully integrated with our long-term partners, who are recognized as industry leaders. ABA is a certified “Great Place to Work”, united by a single mission: standing with members through every moment and milestone in their healthcare journey. With decades of industry experience and a team driven by passion, integrity, and excellence, ABA is committed to delivering connected, transparent, and innovative healthcare solutions to employers and members across the United States.

Requirements

Associate degree preferred; equivalent work experience will be considered.
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.

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 are 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.