Healthcare Claims Audit Specialist

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 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.