Claims Auditor I

Claims AuditorThe Claims Auditor is responsible for conducting comprehensive pre- and post-payment audits of claims processed by New Day Claim Examiners and Associates handling claim underpayment disputes. This role ensures payment accuracy, procedural compliance, and adherence to CMS Medicare guidelines within a managed care health plan environment. The auditor works independently to evaluate claims processing quality, identify discrepancies, and support continuous improvement initiatives.Key ResponsibilitiesPrimary duties may include, but are not limited to:Perform pre- and post-payment audits of claims, including high-dollar and complex claims, across Medicare managed care lines of business.Audit work completed by claim examiners and associates to ensure accuracy in underpayment dispute processing.Validate claim payment accuracy by reviewing:Member eligibilityCoding (CPT, HCPCS, ICD)Pricing and reimbursement methodologiesAuthorization requirementsMedical necessity in accordance with CMS guidelinesEnsure adherence to internal policies, CMS Medicare regulations, and clinical guidelines.Independently interpret medical policies, regulatory requirements, and reimbursement guidelines.Maintain acceptable audit inventory levels and turnaround times.Audit & DocumentationDocument audit findings in detail, including:Decision rationale and methodologyIdentified processing or system errorsFinancial impact and discrepanciesProduce audit reports used for:Financial reconciliationTrend analysisCompliance reportingTrack and trend audit outcomes to identify systemic issues and opportunities for improvement.Quality & Process ImprovementProvide structured feedback and coaching insights to claim examiners and associates.Identify root causes of claim processing errors and recommend corrective actions.Partner with leadership and cross-functional teams to drive quality improvement initiatives.Initiate and support system enhancement requests related to coding, pricing, or workflow inefficiencies.Refer overpayment and recovery opportunities to the appropriate Recovery Team.Collaboration & CommunicationCollaborate with internal departments (e.g., Clinical, Provider Relations, Compliance) to resolve complex claims issues.Contact providers or internal stakeholders to obtain necessary documentation or clarification.Serve as a subject matter expert (SME) on claims auditing standards and Medicare requirements.Minimum QualificationsHigh School Diploma or GED required.Minimum of 5 years of claims processing experience, preferably within healthcare or insurance.At least 1 year of experience in a quality audit or claims auditing role.Experience with Medicare (CMS) guidelines and managed care environments strongly preferred.Equivalent combination of education and experience may be considered.Preferred QualificationsStrong knowledge of:Medical terminologyClaims processing systemsCoding methodologies (CPT, HCPCS, ICD-10)Proven understanding of claims adjudication principles, reimbursement methodologies, and audit techniques.Ability to interpret medical policies and clinical guidelines independently.Experience auditing underpayment disputes or payment integrity functions.Skills & CompetenciesStrong analytical, research, and problem-solving skillsHigh attention to detail and accuracyAbility to work independently in a production-driven environmentEffective written and verbal communication skillsAbility to manage multiple priorities and meet deadlinesProficiency in identifying trends and recommending process improvements