Claims Auditor Senior

Claims Auditor Senior

This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid / virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Claims Auditor Senior is responsible for auditing of high dollar claims across the stop loss business, including complex specialized claims within Service Experience. Serves as the subject matter expert for the unit.

How you will make an impact :

• Performs audits of high dollar claims.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, pre-authorization, and medical necessity.
• Contacts others to obtain any necessary information.
• Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
• Provides feedback on claims processing errors; identifies quality improvement opportunities and initiates complex system requests related to coding or system issues.
• Refers overpayment opportunities to Recovery Team.
• Serves as a subject matter expert for Policy and Clinical Guidelines.
• Associates at this level serve as a mentor and resource to other audit staff.
• Must possess strong research and problem solving skills.

Minimum Requirements :

Preferred Skills, Capabilities & Experiences :

Locations : Illinois, Minnesota & Washington State