Claims Auditor Lead

Claims Auditor Lead

Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless accommodation is granted as required by law.

The Claims Auditor Lead is responsible for processing high dollar claims within Service Operations. Responsible for pre and post payment and adjudication audits of high dollar medical and pharmacy. Serves as the subject matter expert for the unit.

Primary duties may include, but are not limited to:

• Responsible for all team training including but not limited to new hires, cross training, new product and system enhancements.
• Conducts audits for new hires and/or any team member learning a new skill.
• Reviews, interprets and maintains records of quality and productivity for entire team.
• Coaches, mentors and develops associates to ensure processes, guidelines and tools are utilized correctly.
• Utilizes inventory management strategies to monitor priorities and ensure timely turnaround of all claims.
• Responsible for creating, updating and maintaining departmental policy and claims auditor procedure manuals for accuracy.
• Independently analyzes and makes decisions on complex claim audit issues.
• Serves as subject matter expert on policy, workflow and technical questions.
• Interfaces with all levels of support including but not limited to production support, medical management, provider/vendor contracting and other audit teams.
• Partners with Management on complex claims reviews and resolution.
• Responsible for reviewing and resolving shared mailbox issues.
• Interprets contracts, prepares monthly reports, and attends meetings as subject matter expert when requested.
• Manages projects as assigned and may work across different platforms or lines of business.
• Reviews and responds to external audit requests.
• Performs audit reviews of and may adjudicate complex high dollar claims by completing an end to end audit with final approval authority.

Minimum Requirements:

Requires a HS diploma or GED and a minimum of 6 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

Preferred Requirements:

• Proficiency in Microsoft Office Suite is highly preferred.
• Commercial Claims experience is highly preferred
• CI&W and WGS experience is highly preferred.

Job Level: Non-Management Exempt

Workshift: 1st Shift (United States of America)

Job Family: CLM > Claims Support