Claims Auditor I

Job Description

Job Description

Job Summary

The Claims Auditor is responsible for conducting comprehensive pre- and post-payment audits of claims processed by New Day Claim Examiners and Associates handling claim underpayment disputes. This role ensures payment accuracy, procedural compliance, and adherence to CMS Medicare guidelines within a managed care health plan environment. The auditor works independently to evaluate claims processing quality, identify discrepancies, and support continuous improvement initiatives.

Key Responsibilities

Primary duties may include, but are not limited to:

• Perform pre- and post-payment audits of claims, including high-dollar and complex claims, across Medicare managed care lines of business. 
• Audit work completed by claim examiners and associates to ensure accuracy in underpayment dispute processing.
• Validate claim payment accuracy by reviewing: 

• Member eligibility 
• Coding (CPT, HCPCS, ICD) 
• Pricing and reimbursement methodologies 
• Authorization requirements 
• Medical necessity in accordance with CMS guidelines 

• Ensure adherence to internal policies, CMS Medicare regulations, and clinical guidelines. 
• Independently interpret medical policies, regulatory requirements, and reimbursement guidelines. 
• Maintain acceptable audit inventory levels and turnaround times. 

Audit & Documentation

• Document audit findings in detail, including: 

• Decision rationale and methodology
• Identified processing or system errors 
• Financial impact and discrepancies 

• Produce audit reports used for: 

• Financial reconciliation 
• Trend analysis 
• Compliance reporting 

• Track and trend audit outcomes to identify systemic issues and opportunities for improvement. 

Quality & Process Improvement

• Provide structured feedback and coaching insights to claim examiners and associates. 
• Identify root causes of claim processing errors and recommend corrective actions. 
• Partner with leadership and cross-functional teams to drive quality improvement initiatives. 
• Initiate and support system enhancement requests related to coding, pricing, or workflow inefficiencies. 
• Refer overpayment and recovery opportunities to the appropriate Recovery Team. 

Collaboration & Communication

• Collaborate with internal departments (e.g., Clinical, Provider Relations, Compliance) to resolve complex claims issues. 
• Contact providers or internal stakeholders to obtain necessary documentation or clarification. 
• Serve as a subject matter expert (SME) on claims auditing standards and Medicare requirements. 

Minimum Qualifications

• High School Diploma or GED required. 
• Minimum of 5 years of claims processing experience, preferably within healthcare or insurance.
• At least 1 year of experience in a quality audit or claims auditing role.
• Experience with Medicare (CMS) guidelines and managed care environments strongly preferred. 
• Equivalent combination of education and experience may be considered.

Preferred Qualifications

• Strong knowledge of: 

• Medical terminology 
• Claims processing systems 
• Coding methodologies (CPT, HCPCS, ICD-10) 

• Proven understanding of claims adjudication principles, reimbursement methodologies, and audit techniques. 
• Ability to interpret medical policies and clinical guidelines independently. 
• Experience auditing underpayment disputes or payment integrity functions. 

Skills & Competencies

• Strong analytical, research, and problem-solving skills 
• High attention to detail and accuracy 

• Ability to work independently in a production-driven environment 
• Effective written and verbal communication skills 
• Ability to manage multiple priorities and meet deadlines 
• Proficiency in identifying trends and recommending process improvements