Senior Claims Audit & Quality Lead

Highmark Health; Providence (RI); On-site; USD 30,000 - 45,000; Full time

Job summary

Highmark Inc. is seeking a claims auditor to ensure audits are performed in line with internal procedures and contract terms. The role involves reviewing plan wording, monitoring audit workflows, and coaching the claims team to improve accuracy and compliance.

The candidate will maintain knowledge of benefits, state and federal guidelines, and coordinate with supervisors for training and process improvements. Strong CPT/HCPCS/ICD coding knowledge and attention to detail are essential.

Qualifications

• Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 coding.
• Strong attention to detail and organizational skills.
• Ability to work in a fast-paced production environment.
• Excellent communication skills both verbal and written.
• Proficient in MS Excel and MS Word.
• Ability to use judgment to make sound decisions referencing all available resources.
• Ability to work independently and also as part of a team.

Responsibilities

• Handle claims audits and review plan wording.
• Coach and train claims staff; conduct training sessions.
• Record audit results and assist with system upgrades.
• Support SOC, carrier, vendor, and employer audits.
• Liaise with clients and management; manage refunds and stop payments.
• Provide guidance to the claims team on all aspects of claims processing.
• Assist with system upgrade testing.

Skills

CPT/HCPCS

ICD9/ICD10

Attention to detail

Problem solving

Communication skills

Excel basics

Word basics

Independent work

Teamwork

Education

HS/GED

Associate Degree (preferred)

Tools

MS Excel

MS Word

Job description

Highmark Inc. is seeking a claims auditor to ensure audits are performed in line with internal procedures and contract terms. The role involves reviewing plan wording, monitoring audit workflows, and coaching the claims team to improve accuracy and compliance.

The candidate will maintain knowledge of benefits, state and federal guidelines, and coordinate with supervisors for training and process improvements. Strong CPT/HCPCS/ICD coding knowledge and attention to detail are essential.