Claims Auditor

This is a fully remote position, open to applicants in Florida.

📋 Description

• Conduct routine and moderately complex audits of the claims adjudication processes.

• Detect trends, issues, and deviations from established claims adjudication requirements.

• Communicate quality-standard impacts to management.

• Analyze audit performance trends and patterns, recommending enhancements to quality, workflow processes, policies, and procedures.

• Review and finalize contested claims.

• Investigate claim processing issues and errors to determine their sources.

• Provide constructive feedback to examiners, trainers, and management.

• Manually input audit data into the database and generate reports based on audit findings.

• Offer coaching and feedback regarding prepayment and post-payment findings and trends.

• Suggest additional training or updates to mitigate errors and improve service and productivity within Health Net.

• Oversee daily assignments and prioritize older audits to ensure timely completion per regulatory and departmental guidelines.

• Perform other related tasks as assigned.

⛳️ Requirements

• Must have authorization to work in the U.S. without the necessity for employment-based visa sponsorship now or in the future.

• A High School Diploma is required.

• A minimum of one year of relevant experience is necessary.

• Extensive experience in Health Care Claims, Contracts, Benefit Application, and Coordination of Benefits is essential.

• Thorough working knowledge of Policies, Procedures, Compliance Regulations, Schedule of Benefits, and turnaround times across all product lines.

• Capability to engage in specialized training within departments.

🏝️ Benefits

• Health insurance.

• 401K plan.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Additional forms of incentives may be included in total compensation.

• Equal opportunity employer committed to diversity.