Claims Auditor – Medical Stop Loss

Job Description:

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

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.
• 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)

Benefits:

• health and welfare benefits
• tuition and professional certification assistance
• 401k savings
• elective participation in the Employee Stock Purchase Program
• paid time off
• paid holidays
• child bonding leave
• employee assistance