Top 13 Health insurance auditor Jobs

Claims Auditor
Imperial Management Administrators Services Inc —Pasadena, CA
- $30 - $35 an hour
- Microsoft Word
- Microsoft Excel
- Writing skills
Quick Apply
Claims Auditor, Reviewer and Coder
Planned Systems International, Inc. —Remote
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- 5 years
- AD&D insurance
- Disability insurance
Claims Auditor
American Health Plans —Franklin, TN
- Remote
- Mid-level
- Office
- 2 years
- Paid holidays
- Disability insurance
Quick Apply
3d
Staff Auditor
David-James —Baltimore, MD
- $55,000 - $65,000 a year
- Full-time
- Hybrid work
- Analysis skills
- Communication skills
- Entry level
- Health savings account
- Health insurance
Internal Controls Consulting, Consultant
Blue Shield of California —Oakland, CA
- $111,540 - $167,420 a year
- Full-time
- 7 years
- SQL
- Bachelor's degree
Internal Auditor II
HealthPartners/GHI —Bloomington, MN
- $31.38 - $47.06 an hour
- Full-time
- CPA
- Mid-level
- Office
7d
Account Manager
Lockton, Inc. —Houston, TX
- Full-time
- Microsoft Excel
- Microsoft Outlook
- Research
- Wellness program
- Paid parental leave
Commercial Account Manager - WaFd Insurance
WaFd Bank —Carlsbad, NM
- $21.16 - $33.66 an hour
- Full-time
- Mid-level
- Office
- 3 years
- Paid parental leave
- AD&D insurance
Commercial Insurance Account Executive
Swamp Fox Agency LLC —Moncks Corner, SC
- $62,000 - $75,000 a year
- Full-time
- Mid-level
- Continuous improvement
- In-person
- Health insurance
- Dental insurance
Quick Apply
10d
Account Manager
DSB Insurance Group —Wapello, IA
- $45,000 - $55,000 a year
- Full-time
- Background check
- Mid-level
- Business development
- Disability insurance
- Health insurance
Quick Apply
2d

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Manager of Compliance Audit
PROVIDER RESOURCES INC —Remote
Provider Resources Inc. (PRI) is looking for a Manager of Compliance Audit to own our IDR determination audit function.
$105,000 - $155,000 a year
Quick Apply
Auditor, Compliance (Remote in FL)
Molina Healthcare —Florida
Performs on-going compliance audits utilizing as necessary, state evaluation tools relating to audit/monitoring activities.
$54,922 - $107,099 a year

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Claims Auditor

Imperial Management Administrators Services Inc -
Pasadena, CA

Quick Apply

Job Details

$30 - $35 an hour

Qualifications

Microsoft Word
Microsoft Excel
Writing skills
Regulatory compliance in claims processing
English
Medical claims processing software
Health information regulatory compliance
Data interpretation
Centers for Medicare & Medicaid Services (CMS) billing regulations
Clinical confidentiality policies
Medical terminology

Full Job Description

JOB DESCRIPTION

JOB TITLE: Claims Auditor FLSA STATUS: Non-Exempt

DEPARTMENT: Claims Audit

REPORTS TO: Claims Audit Manager / Claims Director

JOB SUMMARY:

The Claims Auditor is responsible for reviewing and auditing claims adjudicated by the system and claims examiners prior to check runs. This role ensures accuracy, identifies errors, verifies compliance with regulatory requirements, and provides recommendations for process and system improvements. The Claims Auditor also supports cross-departmental initiatives to maintain payment integrity and compliance with CMS, Medi-Cal, and commercial guidelines.

ESSENTIAL JOB FUNCTIONS:

Accurately apply Health Plan Benefit Matrices and DOFR (Division of Financial Responsibility) during audits.
Facilitate corrections of claim adjudication errors and recommend process improvements.
Test and audit new releases of Medicare and Medi-Cal Fee Schedules, and provider payment methodologies based on contract agreements.
Maintain a strong understanding of provider contracting arrangements and benefits administration to support accurate and timely claim payments.
Stay current on ICD-10, CPT, HCPCS, Revenue Codes, DRG, and billing procedures for healthcare providers and facilities, as well as Medicare and Medi-Cal reimbursement guidelines.
Test and audit claim payments for accuracy against contract data in E-CAP.
Generate and analyze audit reports to identify adjudication errors, overpayments, and underpayments.
Document audit findings with detailed review process, justification, and conclusions.
Track and analyze errors to identify trends and recommend training or system enhancements.
Provide training and mentoring for new staff to improve accuracy and productivity.
Maintain detailed knowledge of EZ-CAP rules related to claims payment.
Ensure compliance with claim timeliness standards:

Commercial: 45 working days
Medi-Cal: 30 calendar days
Medicare non-contracted: 30 calendar days
Medicare Contracted: 60 calendar days

Collaborate with the Recovery Team on overpayment resolution.
Perform Coordination of Benefits (COB) reviews as applicable.
Support overall business needs of the Claims Department and contribute to team goals.
Consistently meet productivity and quality standards as defined by management.

MARGINAL JOB FUNCTIONS:

Take on special projects as needed.
Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

Continuous Learning:

a. Attend required staff meetings.

b. Participate in relevant training, seminars, and workshops to stay informed and up to date.

Customer Focus:

Maintain client/customer confidentiality and privacy in compliance with HIPAA regulations and IMAS's Standards of Conduct.
Foster effective communication and collaboration with supervisors, co-workers, and other staff members.

Quality/Process Improvement/Safety

a. Report any security, health, or safety issues to the appropriate supervisor as soon as possible.

b. Demonstrate a commitment to safety in all duties performed.

c. Follow established policies, procedures, and comply with all regulatory standards set by governing entities.

POSITION REQUIREMENTS:

EDUCATION/EXPERIENCE:

Minimum 2 years’ experience in complex claims processing and/or auditing in the health insurance industry.
EZ-CAP knowledge strongly preferred.

SKILLS/KNOWLEDGE/ABILITY:

Strong knowledge of healthcare regulations and guidelines (CMS, DMHC, DHS).
Proficiency in claims coding and forms (CCI, CMS-1500, UB-04, CPT, ICD-10, HCPCS).
Familiarity with EZ-CAP or similar claims processing systems.
Proficiency in Microsoft Word and Excel; basic understanding of medical terminology.
Excellent organizational, multitasking, and deadline management skills.
Strong analytical and problem-solving abilities with keen attention to detail.
Ability to exercise sound judgment and work independently or collaboratively.
Strong written and verbal communication skills.
Ability to multitask and effectively solve problems in a fast-paced work environment.
Proficiency in reading, writing, speaking, and understanding English, with the necessary communication skills to provide accurate information to residents and staff.
Ability to follow both written and verbal instructions in English.
Commitment to maintaining appropriate levels of confidentiality and privacy in all interactions.
Professional demeanor and ability to interact courteously with customers, members, and co-workers, both independently and as part of a team.
Ability to effectively manage multiple tasks and adapt to shifting priorities as required.
Strong decision-making and problem-solving skills, with the ability to make appropriate judgments in a timely manner.
Ability to prioritize tasks effectively, ensuring that key items are addressed efficiently.
Self-motivated and capable of taking initiative as a self-starter.
Willingness and ability to understand and comply with all relevant Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING:

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health insurance auditor jobs

Claims Auditor

Claims Auditor, Reviewer and Coder

Claims Auditor

Staff Auditor

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Internal Auditor II

Account Manager

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