Specific Claims Auditor
J
JobgetherHealth Insurance
Remote work opportunity within the United StatesFull-TimeMiddle
Salary$40,300–$80,800, with geographic adjustments where applicable.
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Job Details
- Required Skills
- Microsoft AccessMicrosoft ExcelPowerPointHIPAA
Requirements
- Strong medical knowledge, including ICD, CPT, medical terminology, COBRA, HIPAA, and related healthcare and insurance concepts.
- Ability to read, interpret, and apply health plan documents, benefit provisions, claim reports, procedural manuals, and insurance policies.
- Demonstrated understanding of claims administration principles, practices, procedures, and liability assessment.
- Strong analytical and organizational skills, with the ability to manage multiple claims, priorities, and deadlines accurately.
- Excellent written and verbal communication skills, with a professional approach to confidentiality, tact, and diplomacy.
- Ability to exercise sound judgment when reviewing claim documentation, determining liability, establishing reserves, and escalating issues.
- Intermediate proficiency with Microsoft Office, including Excel, Access, PowerPoint, and Word.
- Ability to stay current with industry changes, legal updates, and technical developments relevant to healthcare claims and specialty insurance.
- Strong attention to detail and the ability to work independently while following established policies, procedures, and departmental standards.
Responsibilities
- Review and interpret employer health plans, excess insurance policies, claim reports, and related documentation to determine individual claim liability.
- Audit submitted claim information for completeness and accuracy, verifying that benefits have been paid appropriately and in accordance with applicable plans, contracts, and policies.
- Investigate claim details and determine the extent of coverage and financial liability within established departmental standards and timelines.
- Communicate with third-party administrators and clients by phone and in writing to clarify information, resolve processing issues, and explain coverage decisions.
- Establish claim reserves based on anticipated liability and adjust reserves as necessary to keep them accurate and current.
- Authorize claim payments within the applicable liability limits and communicate the rationale for amounts that are not covered under the excess policy.
- Escalate large-dollar claims and claims involving trigger diagnoses to preliminary claims and case management teams for further review.
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