Claims Auditor: Medical Plan Audits & Coaching

Highmark Health; Kentucky; Hybrid; USD 30,000 - 45,000; Full time

Job summary

Highmark Health in the United States (KY region) seeks a Claims Audit Specialist with 5 years of medical claims processing experience in dental, vision, FSA and HRA. You will ensure claims follow procedures, monitor audits, record results, and coach staff to maintain accuracy and efficiency.

You will support supervision, recommend dollar authorizations based on audit stats, conduct specialized audits, and test system upgrades.

Qualifications

• Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding.
• Strong attention to detail and organizational skills.
• Ability to problem solve and work in a fast-paced environment.
• Excellent written and verbal communication skills.
• Basic MS Excel and Word proficiency.
• Use good judgment referencing all resources to decide on next steps.
• Ability to work independently and as part of a team.

Responsibilities

• Ensure all claims are handled per internal procedures and review plan wording.
• Monitor audits to meet turnaround time and identify performance issues.
• Maintain workload to meet quality and production standards.
• Record results in the audit tool for monthly reporting.
• Coach staff one-on-one and provide guidance on audits.
• Make recommendations for dollar authorization based on audit stats.
• Assist with specialized SOC, carrier, vendor and employer audits.
• Maintain knowledge of benefits, regulations and system upgrades.
• Provide expertise to claims team for complex claim issues.
• Liaise with clients and management using strong communication.
• Manage refund, void and stop payment processes.
• Assist with system upgrade testing and other duties as assigned.

Skills

CPT coding

HCPCS coding

ICD9/ICD10

Detail orientation

Problem solving

Communication skills

MS Excel

MS Word

Independent & team work

Education

HS/GED

Associate Degree

Job description

Highmark Health in the United States (KY region) seeks a Claims Audit Specialist with 5 years of medical claims processing experience in dental, vision, FSA and HRA. You will ensure claims follow procedures, monitor audits, record results, and coach staff to maintain accuracy and efficiency.

You will support supervision, recommend dollar authorizations based on audit stats, conduct specialized audits, and test system upgrades.