Claims Audit Specialist - Medical Benefits

Highmark Health; Santa Fe (NM); On-site; USD 46,000 - 69,000; Full time

Job summary

Highmark Inc. is seeking a claims audit specialist to ensure claims are processed in line with internal procedures and plan documents. You will monitor audit workflows, support monthly reporting, and coach team members to improve accuracy and speed.

The role requires strong knowledge of CPT/HCPCS/ICD9/ICD10 coding, excellent communication, and the ability to work independently or as part of a team in a fast-paced setting. Training and system upgrade testing are also part of the duties.

Qualifications

• Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding.
• Strong attention to detail and organizational skills.
• Excellent problem-solving abilities in a fast-paced production environment.
• Excellent verbal and written communication skills.
• Proficient PC navigation in a professional setting.
• Basic MS Excel and MS Word skills.
• Ability to exercise judgment and make sound decisions with available resources.
• Ability to work independently and as part of a team.

Responsibilities

• Ensure claims handling aligns with internal procedures and plan documents.
• Monitor audits to meet tight turnaround times and quality standards.
• Coach claims team and provide training on audit findings.
• Record audit results and support monthly reporting.
• Provide guidance on complex claim issues and SOC/process audits.
• Assist with system upgrade testing and validation.
• Liaise with clients and management to communicate audit outcomes.
• Manage refund, void, and stop payment processes.
• Handle additional duties as assigned by management.

Skills

Medical coding

Attention to detail

Problem solving

Communication

PC navigation

MS Excel (Basic)

MS Word (Basic)

Judgment

Teamwork

Education

HS/GED

Associate Degree preferred

Job description

Highmark Inc. is seeking a claims audit specialist to ensure claims are processed in line with internal procedures and plan documents. You will monitor audit workflows, support monthly reporting, and coach team members to improve accuracy and speed.

The role requires strong knowledge of CPT/HCPCS/ICD9/ICD10 coding, excellent communication, and the ability to work independently or as part of a team in a fast-paced setting. Training and system upgrade testing are also part of the duties.