Claims Auditor Lead
Core
Leading high-dollar audit team for pre and post payment and adjudication audits of medical and pharmacy claims.
Role type
Senior IC claims auditor lead
Builds
Accurate adjudication decisions and compliant claims processing for high-dollar medical and pharmacy claims
Domain
Healthcare insurance / Claims operations
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Quality audit, team training and coaching, policy interpretation, complex claim analysis, inventory management, project management, contract interpretation, report preparation, cross-functional collaboration
Preferred skills
Stop loss insurance experience, Microsoft Office Suite proficiency
Technologies
Microsoft Office Suite
Responsibilities
Lead high-dollar audit team; conduct audits for new hires and team members learning new skills; review and maintain quality and productivity records; coach and mentor associates; monitor priorities and ensure timely turnaround; create and update departmental policy and procedure manuals; analyze and decide on complex claim audit issues; interface with support, medical management, and provider contracting teams; partner with management on complex claims resolution; resolve shared mailbox issues; prepare monthly reports; manage assigned projects; review and respond to external audit requests; perform end-to-end audits with final approval authority for complex high-dollar claims
Seniority
Senior, hands-on IC