Specific Claims Auditor

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

📋 Description

• Conducts investigations into claims liability and assesses the extent of responsibility for submitted claims related to specific individuals.

• Processes claims accurately in accordance with existing policies or contracts, adhering to departmental timelines and standards.

• Establishes reserves pertinent to claim liability.

• Reviews and interprets employer health coverage plans and excess insurance policies in relation to individual claims.

• Audits submitted claim documents to ensure sufficient data is present, verifying that benefits were disbursed correctly and according to relevant plans and policies.

• Engages in written and verbal communication with third-party administrators (TPA) or clients as necessary to address claim processing issues.

• Sets and adjusts claims reserves as required.

• Maintains up-to-date reserves.

• Authorizes checks reflecting the liability amount and informs the TPA/client of any amounts not covered by the excess policy.

• Refers large-dollar claims and trigger diagnoses to preliminary claims and case management departments.

⛳️ Requirements

• Bachelor's Degree in Business Administration, a related field, or equivalent education and/or experience.

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

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

• Knowledge of principles, practices, and procedures and the ability to apply this knowledge effectively.

• Excellent written and verbal communication skills, emphasizing confidentiality, tact, and diplomacy.

• Advanced organizational and analytical capabilities; proven ability to manage multiple tasks concurrently.

• Awareness of industry shifts, legal updates, and technical developments relevant to the Company's business, enabling proactive responses to the evolving business landscape.

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

🏝️ Benefits

• Comprehensive medical, vision, and dental coverage, with eligibility starting on your first day of employment.

• Basic life and disability insurance.

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

• 20 days of PTO, two floating holidays, approximately 11 paid holidays, and volunteer time off.

• Paid parental leave.

• Access to our award-winning wellness program, which includes mental health services, a fitness network membership, and a complimentary Headspace subscription.

• Student loan matching program.

• Employee discount program.