Specific Claims Auditor
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Job Description
Claims Auditor reviewing and interpreting employer health coverage plans and submitting claims. Investigating claims liability and ensuring compliance with appropriate policies and plans.
Responsibilities:
- Investigates claims liability and determine the extent of liability on a submitted claim for a specific individual
- Accurately processes the claim according to the policies or contracts that exist, within the departmental time frames and standards
- Establishes reserves for claim liability
- Reviews and interprets employer plans of health coverage and excess insurance policy to individual claims
- Audits submitted claim documents for sufficient data, verifying that benefits were paid correctly and in accordance with appropriate plans and policies
- Communicates in writing and verbally with third-party administrator (TPA)/client, as needed, to resolve claim processing issues
- Sets claims reserves and adjusts as needed
- Keeps the reserves current
- Authorizes checks for amount of liability and communicates to TPA/client reasons for any amounts not covered by excess policy
- Refers large-dollar claims and trigger diagnosis to preliminary claims and case management departments
Requirements:
- 4 Year / Bachelors Degree Business Administration, a related field, or the equivalent education and/or experience
- Strong medical knowledge including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPPA
- Ability to read and interpret documents such as Plan of Benefits, claim reports, and procedural manuals
- Possess and have ability to apply knowledge of principles, practices, and procedures
- Solid written and verbal communication skills with an emphasis on confidentiality, tact, and diplomacy
- Advanced organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously
- Knowledgeable of industry changes, legal updates, and technical developments related to applicable area of the Company’s business to proactively respond to changing business environment
- Intermediate proficiency and experience using Microsoft Office package (Excel, Access, PowerPoint, Word)
Benefits:
- Comprehensive medical, vision, and dental coverage, with eligibility beginning on your first day of employment
- Basic life and disability insurance
- 401(k) plan with 6% company match
- 20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off
- Paid parental leave
- Access to our award-winning wellness program, including mental health services, fitness network membership, and a complimentary Headspace subscription
- Student loan matching program
- Employee discount program
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