Specific Claims Auditor

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

📋 Description

• Investigate liability for claims and assess the extent of responsibility for submitted individual claims.

• Efficiently process claims in accordance with relevant policies or contracts while adhering to departmental timelines and standards.

• Establish and maintain reserves pertaining to claim liability.

• Review and analyze employer health coverage plans and excess insurance policies for individual claims.

• Audit submitted claim documentation to ensure adequate data is present.

• Confirm that benefits were disbursed accurately and in line with applicable plans and policies.

• Communicate both in writing and verbally with third-party administrators (TPAs) and clients to address any claim processing challenges.

• Set and modify claims reserves as required and keep them updated.

• Approve checks corresponding to liability amounts.

• Explain reasons for amounts not covered by the excess policy to TPAs and clients.

• Refer significant claims and key diagnoses to preliminary claims and case management departments.

⛳️ Requirements

• Strong knowledge of medical concepts including International Classification of Diseases (ICD), Current Procedural Terminology (CPT), medical terminology, COBRA, and HIPAA.

• Capability to read and interpret documents such as Plans of Benefits, claim reports, and procedural manuals.

• Ability to apply knowledge of principles, practices, and procedures effectively.

• Excellent written and verbal communication skills with a focus on confidentiality, tact, and diplomacy.

• Advanced organizational and analytical capabilities.

• Proven ability to manage multiple tasks concurrently.

• Awareness of industry shifts, legal updates, and technical advancements related to the relevant area of the Company’s operations.

• Intermediate proficiency and experience with the Microsoft Office suite (Excel, Access, PowerPoint, Word).

🏝️ Benefits

• Generous paid time off (PTO).

• 12 paid company holidays.

• 401(k) Retirement Plan with a 6% company match.

• Health and dental insurance.

• Vision plan.

• Company-sponsored long-term disability and life insurance.

• Opportunities for career advancement.

• Flexible work schedules.

• Work/life balance.

• Paid Parental Leave.

• Volunteer Time Off.

• Casual dress code.

• Modern and comfortable office environment with free parking.