Job Description:
Title: Claims Auditor I
Location: This position will work a remote model. Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The Claims Auditor I is responsible for pre and post payment and adjudication audits of high dollar claims for limited lines of business, claim types and products including specialized claims with appropriate guidance from management and peers.
How you will make an impact:
- Performs audits of and may adjudicate high dollar claims while maintaining acceptable levels of claims inventory and age.
- Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, system coding and pricing, pre-authorization, and medical necessity.
- Contacts others to obtain any necessary information.
- Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
- Provides feedback on processing errors; identifies quality improvement opportunities and initiates basic requests related to coding or system issues, where applicable.
- Refers overpayment opportunities to Recovery Team.
Minimum Requirements
- Requires a HS diploma or GED and a minimum of 3 years of claims processing experience; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences
- Working knowledge of insurance industry and medical terminology; working knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines highly preferred.
- Ability to acquire and perform progressively more complex skills and tasks in a production environment highly preferred.
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