Claims Auditor II

100 Horizon Healthcare Services, Inc; Newark (NJ); On-site; USD 63,000 - 84,000; Full time

Benefits offered by this job

Comprehensive health benefits (Medical

Retention Plans

Generous PTO

Incentive Plans

Wellness Programs

Paid Volunteer Time Off

Tuition Reimbursement

Job summary

Horizon Blue Cross Blue Shield of New Jersey is seeking an Audit Specialist to perform sampling across benefit coding, reimbursement, and claims to ensure adjudication accuracy.

You will independently review audit samples, cite findings with supporting evidence, and maintain organized documentation while collaborating with business areas to resolve root causes. A high school diploma and 3–5 years of claims processing experience are required.

Qualifications

• High School Diploma or GED required.
• 3-5 years of claims processing experience required.
• Knowledge of NASCO system

Responsibilities

• Review audit samples across PG, LOS, LDLA, and FEP audit programs, per criteria.
• Complete assigned audit volumes within production expectations with accuracy and documentation.
• Identify processing errors, cite findings with rationale and supporting evidence.
• Manage audit points through follow-up and closure within established timeframes.
• Collaborate with business areas to obtain clarification and resolve root causes.
• Use NASCO, Blue Squared, Local, BlueCard and other systems to document results.
• Maintain complete, organized audit documentation for findings and reports.
• Support calibration and onboarding of less experienced auditors as appropriate.
• Escalate unclear or complex scenarios to senior auditors as needed.
• Perform other duties as assigned by management to meet needs.

Skills

Claims processing

Education

High School Diploma/GED

Tools

NASCO

Job description

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds.

About the Role

Performs audit samples on benefit coding, reimbursement, pricing, PIBA and pharmacy to ensure accurate claim adjudication and reimbursement.

What You’ll Do

Independently review assigned audit samples across PG, LOS, LDLA, and FEP audit programs, including claims, EDI, portal, inquiries, membership, and other operational work types, in accordance with established audit criteria and program-specific guidance.

Complete assigned audit volumes within established production expectations while maintaining required accuracy, quality, and documentation standards.

Identify processing errors, variances, or noncompliant outcomes during sample review; cite findings as audit points; and document rationale and supporting evidence clearly, accurately, and independently.

Manage assigned audit points through follow-up and resolution activities, including communication, validation, documentation updates, and closure within established timeframes.

Partner with business areas and internal team members to obtain clarification, confirm root-cause information, support audit point resolution, and ensure findings are addressed appropriately.

Use applicable systems and tools to complete audit work and document results, including NASCO, Blue Squared, Local, BlueCard, other supporting operational systems, and the department’s audit tool.

Maintain complete, accurate, and organized audit documentation to support findings, audit point activity, re-review, reporting, and audit readiness.

Support consistency across the audit function by participating in calibration activities, sharing knowledge, and assisting with onboarding or guidance for less experienced auditors as appropriate.

Escalate unclear, conflicting, or complex scenarios to senior auditors or management, as appropriate, while demonstrating sound judgment and increasing independence in audit execution.

Perform other job-related duties, special assignments, and operational support activities, as assigned by management, to meet departmental, regulatory, and business needs.

What You Bring

Education/Experience: High School Diploma/GED required. 3-5 years of claims processing experience required.

Knowledge: Systems knowledge (e.g. NASCO).

Why Horizon?

At Horizon, you’ll do meaningful work that directly improves lives - while being supported by a mission-driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too.

Salary Range: $63,000 - $84,420 This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case.

Benefits and Compensation Package

• Comprehensive health benefits (Medical/Dental/Vision)
• Retirement Plans
• Generous PTO
• Incentive Plans
• Wellness Programs
• Paid Volunteer Time Off
• Tuition Reimbursement

Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity or protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law.

Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

Horizon BCBSNJ is the leading health insurer in New Jersey, trusted by generations of families and businesses. We are dedicated to enriching the lives and health of our members and the New Jersey communities we serve, because we live and work here too.