About the Role
The Medical Claims Auditor is responsible for evaluating submitted medical claims to verify coding accuracy, adherence to policies, and regulatory compliance. This role supports the integrity of claims processing and helps improve overall system efficiency.
Responsibilities
- Examine medical claims for correct coding and documentation
- Identify discrepancies between billed services and medical records
- Ensure compliance with federal, state, and payer-specific regulations
- Collaborate with clinical and coding teams to resolve issues
- Maintain accurate audit records and documentation
- Report findings to management with recommendations for improvement
- Support process improvements to reduce claim errors
- Conduct retrospective and prospective claim reviews
- Assist in training staff on coding and documentation standards
- Monitor trends in claim denials and errors
- Use data analysis tools to identify patterns in claims data
- Verify medical necessity based on clinical guidelines
- Review electronic health records to support audit findings
- Communicate with providers when clarification is needed
- Ensure patient privacy and data security during audits
- Stay current with changes in healthcare regulations and coding standards
- Participate in internal audits and quality assurance initiatives
- Support external audit preparation and response
- Evaluate documentation sufficiency for risk adjustment purposes
- Assist in developing audit protocols and workflows
- Track key performance metrics related to claim accuracy
- Escalate systemic issues to leadership
- Contribute to policy and procedure updates
- Work cross-functionally with data, clinical, and operations teams
- Promote a culture of compliance and continuous improvement
Compensation
Competitive salary and benefits package offered
Work Arrangement
Hybrid work model with flexibility for remote and office-based work
Team
Part of the healthcare operations team focused on claims accuracy and compliance
Why This Role Matters
Accurate claims auditing ensures patients receive appropriate care and payers process claims correctly. This role directly impacts financial integrity and regulatory compliance, helping to maintain trust in the healthcare system.
What You’ll Bring
A strong ethical foundation, precision in analysis, and dedication to improving healthcare outcomes through accurate data. You must be comfortable interpreting clinical records and advocating for compliance.
Not available for this position
