Claims Auditor-Auditing Claims

We are seeking an experienced Claims Auditor to join a healthcare organization and support the accuracy and quality of Medicare claims processing. This position will be responsible for performing pre- and post-payment audits, identifying discrepancies, ensuring compliance with CMS guidelines, and helping improve overall claims processing quality.

Responsibilities

Perform pre- and post-payment audits of healthcare claims, including high-dollar and complex claims.

Review claims processed by claims examiners for accuracy and compliance.

Validate member eligibility, coding, pricing, reimbursement, authorization requirements, and medical necessity.

Review CPT, HCPCS, and ICD-10 coding.

Ensure claims are processed according to CMS Medicare guidelines, internal policies, and clinical requirements.

Audit underpayment disputes and identify payment discrepancies or processing errors.

Document audit findings, financial discrepancies, and decision rationale.

Track audit trends and identify recurring claims processing issues.

Recommend corrective actions and process improvements.

Work with internal departments to research and resolve complex claims issues.

Provide feedback regarding claims processing errors and quality concerns.

Identify potential overpayment and recovery opportunities.

Qualifications

High School Diploma or GED required.

5+ years of claims processing experience , preferably within healthcare or insurance.

1+ year of claims auditing or quality audit experience required.

Medicare/CMS and managed care experience strongly preferred.

Strong understanding of claims adjudication and reimbursement methodologies.

Knowledge of CPT, HCPCS, and ICD-10 coding .

Strong knowledge of medical terminology and claims processing systems.

Experience with underpayment disputes or payment integrity is a plus.

Strong analytical, research, and problem-solving skills.

Excellent attention to detail and accuracy.

Ability to work independently and manage multiple priorities in a production-driven environment.

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