Senior Claims Auditor - Accident & Health

Skyward Specialty•Kennesaw, GA

32d•$90,000 - $110,000•Hybrid

About The Position

We are seeking an experienced and detail-oriented Senior Accident and Health Claims Auditor to join our team. The ideal candidate will have extensive knowledge of insurance claims processes, auditing standards, and regulatory requirements related to accident and health insurance. The Senior Auditor will play a key role in ensuring the accuracy, compliance, and integrity of claims processed, identifying potential areas of improvement, and providing leadership in audit initiatives.

Requirements

Bachelor’s degree in business, Insurance, or related field (preferred)
Minimum 3+ years in experience in medical claims auditing and processing in accidental and health insurance claims.
Robust knowledge of claims processing systems, protocols, and regulatory requirements.
Excellent analytical, problem-solving, and decision-making skills.
Strong attention to detail and organizational abilities.

Nice To Haves

Advanced knowledge of claims processing guidelines, medical terminology (ICD-10, CPT, HCPCS, UB04), and insurance concepts (UCR, COB, HIPAA, subrogation)
Familiarity with eligibility guidelines and group health plan administration (Medicare, COBRA, FMLA, etc.)
Strong analytical skills with attention to detail and proficiency in interpreting Plan Documents and reinsurance contracts.
Excellent written and verbal communication skills with proven customer service.
Effective problem-solving, team partnership, and project management abilities
Proficiency with claims processing systems and Microsoft Office Suite (Word, Excel, PowerPoint)
Ability to foster a collaborative team environment and drive continuous improvement initiatives.

Responsibilities

Claims Audit: Conduct thorough audits of accident and health insurance claims to verify accuracy, policy compliance, and proper adjudication.
Compliance Verification: Ensure claims adhere to company policies, industry regulations, and legal requirements, including HIPAA.
Data Analysis: Analyze claims data to identify patterns, discrepancies, and opportunities for process improvement.
Reporting: Prepare detailed audit reports and communicate findings, recommendations, and corrective actions to management and relevant departments.
Process Improvement: Collaborate with claims processing teams to implement audit recommendations, streamline workflows, and enhance claims accuracy.
Training & Mentorship: Serve as a subject matter expert by training junior auditors and claims processors on audit procedures and compliance standards.
Documentation: Maintain accurate documentation of audit processes, findings, and follow-up actions, ensuring all information is safeguarded and confidential.
Continuous Learning: Stay updated on changing regulations, industry best practices, and emerging audit methodologies.