Claims Auditor I, II & Senior

About the position Claims Auditor I, II and Senior Location : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. The Claims Auditor I is responsible for pre and post payment and adjudication audits of high dollar claims for limited lines of business, claim types and products including specialized claims with appropriate guidance from management and peers. The Claims Auditor II is responsible for audits of high dollar claims across the stop loss business, including specialized claims, working independently and without significant guidance. The Claims Auditor Senior is responsible for auditing of high dollar claims across the stop loss business, including complex specialized claims within Service Experience. Serves as the subject matter expert for the unit. How you will make an impact : Performs audits of high dollar claims. Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, pre-authorization, and medical necessity. Contacts others to obtain any necessary information. Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis. Provides feedback on processing errors; identifies quality improvement opportunities and initiates basic requests related to coding or system issues, where applicable. Refers overpayment opportunities to Recovery Team. Claims Auditor II - all the above, plus: Independently interprets Medical Policy and Clinical Guidelines. Claims Auditor Senior - all the above, plus : Service as a subject matter expert for Policy and Clinical Guidelines. Associates at this level serve as a mentor and resource to other audit staff. Must possess strong research and problem solving skills.

Responsibilities

• Performs audits of high dollar claims.
• Ensures claim payment accuracy by verifying various aspects of the claim including eligibility, pre-authorization, and medical necessity.
• Contacts others to obtain any necessary information.
• Completes and maintains detailed documentation of audit which includes decision methodology, system or processing errors, and monetary discrepancies which are used for financial reporting and trending analysis.
• Provides feedback on processing errors; identifies quality improvement opportunities and initiates basic requests related to coding or system issues, where applicable.
• Refers overpayment opportunities to Recovery Team.
• Independently interprets Medical Policy and Clinical Guidelines.
• Service as a subject matter expert for Policy and Clinical Guidelines.
• Associates at this level serve as a mentor and resource to other audit staff.
• Must possess strong research and problem solving skills.

Requirements

• Claims Auditor I : Requires a HS diploma or GED and a minimum of 3 years of claims processing experience; or any combination of education and experience which would provide an equivalent background.
• Claims Auditor II : Requires a HS diploma or GED and a minimum of 5 years of claims processing experience including a minimum of 1 year related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.
• Claims Auditor Senior : Requires a HS diploma or GED and a minimum of 4 years related experience in a quality audit capacity (preferably in healthcare or insurance sector); or any combination of education and experience which would provide an equivalent background.

Nice-to-haves

• Stop loss claims experience highly preferred.
• Working knowledge of insurance industry and medical terminology; working knowledge of relevant systems and proven understanding of processing principles, techniques and guidelines strongly preferred.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment strongly preferred.
• Strong research and problem solving skills preferred.

Benefits

• In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

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