Claims Auditor, Health Plan

The Claims Auditor is responsible for performing payment, procedural accuracy, turnaround time, compliance and operational audits on claims; reviews CPT/ICD/HCPCS coding and modifiers; ensures proper billing and adherence to CMS, Medicaid, and insurer policies; develops and maintains knowledge of coding guidelines and audit programs; conducts monthly pre-pay and post-paid claim audits; analyzes claim processing variances and reports findings to management; reviews medical records to assess charges; utilizes auditing applications and claims systems to document audits; prepares concise reports and recommendations to improve processes and claim workflows; CPC or CPC-P certification is preferred.