Claims Audit & Quality Specialist

highmarkhealth; Pennsylvania; Hybrid; USD 30,000 - 45,000; Full time

Job summary

Highmark Health seeks a senior claims auditor to ensure accurate processing of medical, dental, and vision benefits. You will review plans, monitor audits, and coach staff while maintaining high standards of accuracy and efficiency.

The role requires extensive coding knowledge, 5 years of experience, and strong communication skills. Competitive pay and benefits accompany a structured environment with opportunities for system upgrades testing.

Qualifications

• Strong knowledge of CPT, HCPCS, ICD9 and ICD10 coding.
• 5 years medical/dental/vision, FSA and HRA claims processing experience.
• Attention to detail and organizational skills.
• Excellent verbal and written communication skills.
• Proficiency with MS Excel and MS Word.
• Ability to use judgement to make sound decisions with available resources.
• Ability to work independently and as part of a team.

Responsibilities

• Handle claims per internal procedures and review plan documents for each employer group.
• Monitor audits to ensure timely turnaround and identify performance issues.
• Maintain workload to meet quality and production standards for the auditing team.
• Record results in the audit tool and assist supervisor with training sessions.
• Conduct one-on-one coaching with trainee staff.
• Provide recommendations for dollar authorization based on audit stats.
• Assist with SOC, carrier, vendor and employer audits as needed.
• Maintain knowledge of benefits, state/federal regulations and system upgrades.
• Provide expertise to claims team on complex claims to render sound decisions.
• Liaise with clients and internal teams using clear written or verbal communication.
• Manage refund, void and stop payment processes.
• Guide the claims team on all aspects of claims processing.
• Assist in system upgrade testing.
• Handle other duties as assigned.

Skills

CPT/HCPCS/ICD9/ICD10

Attention to detail

Problem solving

Communication skills

MS Excel

MS Word

Judgment

Independent & team work

Time management

Education

HS/GED

Associate degree (preferred)

Tools

MS Word

Job description

Highmark Health seeks a senior claims auditor to ensure accurate processing of medical, dental, and vision benefits. You will review plans, monitor audits, and coach staff while maintaining high standards of accuracy and efficiency.

The role requires extensive coding knowledge, 5 years of experience, and strong communication skills. Competitive pay and benefits accompany a structured environment with opportunities for system upgrades testing.