Claims Auditor II
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Job Description
Claims auditor reviewing health insurance claims, coding, reimbursement, and pricing for Horizon Blue Cross Blue Shield of New Jersey. Documenting audit findings and resolving processing errors.
Responsibilities:
- Perform audit samples on benefit coding, reimbursement, pricing, PIBA and pharmacy to ensure accurate claim adjudication and reimbursement.
- Independently review assigned audit samples across PG, LOS, LDLA, and FEP audit programs, including claims, EDI, portal, inquiries, membership, and other operational work types.
- Complete assigned audit volumes while maintaining accuracy, quality, and documentation standards.
- Identify processing errors, variances, or noncompliant outcomes; cite audit points; and document rationale and supporting evidence.
- Manage audit points through follow-up, validation, documentation updates, and closure.
- Partner with business areas and internal team members to clarify information, confirm root causes, and resolve findings.
- Use NASCO, Blue Squared, Local, BlueCard, supporting operational systems, and the department’s audit tool.
- Maintain organized audit documentation for findings, re-review, reporting, and audit readiness.
- Participate in calibration activities, share knowledge, and assist with onboarding or guidance for less experienced auditors.
- Escalate unclear, conflicting, or complex scenarios to senior auditors or management.
- Perform other job-related duties, special assignments, and operational support activities as assigned.
Requirements:
- High School Diploma/GED required.
- 3-5 years of claims processing experience required.
- Knowledge of systems such as NASCO.
- Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.
Benefits:
- Comprehensive health benefits (Medical/Dental/Vision)
- Retirement Plans
- Generous PTO
- Incentive Plans
- Wellness Programs
- Paid Volunteer Time Off
- Tuition Reimbursement
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