Senior Claims Audit & Compliance Specialist

Highmark Health Company; Madison (WI); On-site; USD 30,000 - 45,000; Full time

Job summary

Highmark Inc. in Madison, WI is seeking a claims audit specialist to ensure claims are processed according to procedures and plan documents. The role involves monitoring audits, coaching staff, and providing expertise on complex claim situations.

Qualified candidates will have 5 years of claims processing experience, strong CPT/HCPCS/ICD9/ICD10 knowledge, and excellent communication skills. The position requires independence and teamwork in a fast-paced environment.

Qualifications

• 5 years prior medical claims processing experience.
• Strong CPT/HCPCS/ICD9/ICD10 knowledge.
• Excellent written and verbal communication.
• Ability to work in fast-paced production environment.
• Detail-oriented with strong organizational skills.
• Ability to work independently and in a team.

Responsibilities

• Ensure claims handling per procedures and plan documents.
• Monitor audits and ensure timely turnaround.
• Maintain workload to meet quality standards.
• Record results in audit tool and train staff.
• Coach claims team, especially trainees.
• Provide recommendations for dollar authorization.
• Assist with SOC process, carrier and employer audits.
• Stay updated on benefits, regulations, system upgrades.
• Provide expertise on complex claim issues.
• Liaise with clients and internal teams.
• Manage refunds, voids and stop payments.
• Assist with system upgrade testing.
• Handle other duties as assigned.

Skills

Medical coding

Attention to detail

Problem solving

Communication skills

MS Excel

MS Word

Team player

Independent worker

Education

High school diploma or GED

Associate degree preferred

Tools

Audit tool

Job description

Highmark Inc. in Madison, WI is seeking a claims audit specialist to ensure claims are processed according to procedures and plan documents. The role involves monitoring audits, coaching staff, and providing expertise on complex claim situations.

Qualified candidates will have 5 years of claims processing experience, strong CPT/HCPCS/ICD9/ICD10 knowledge, and excellent communication skills. The position requires independence and teamwork in a fast-paced environment.