Senior Claims Auditor - Managed Care

The Senior Claims Auditor serves as the technical lead for complex claims auditing activities. This role is responsible for developing and maintaining audit methodologies, overseeing the accuracy and compliance of claims processing with department policies, CMS, DMHC, and other regulatory standards, and providing advanced analytical support to management. The incumbent leads cross departmental audit initiatives, performs specialized system testing, and supports internal and external regulatory audits.

Duties and Responsibilities

• Designs, updates, and implements audit methodologies and selection criteria based on prior audit results, regulatory changes, system improvements, and operational trends.
• Conducts advanced audits on adjudicated claims, including high risk and complex cases, ensuring compliance with policies, payment methodologies, and regulatory requirements.
• Performs EPIC/Tapestry system testing and validation to ensure claim processing systems and EIS updates function as intended.
• Serves as primary resource for internal audits, providing detailed validation and documentation.
• Develops, maintains, and updates departmental SOPs for claims auditing. Mentors and provides technical guidance to junior Claims Auditors.
• Analyzes audit results to identify trends, root causes, and systemic issues. Delivers actionable recommendations to management for process and operational improvements.
• Leads cross functional projects involving claims operations, IT, compliance, and other departments to resolve complex audit findings.
• Produces written and verbal reports summarizing audit findings for leadership, highlighting compliance risks and recommending mitigation strategies.
• Monitors appeals and disputes involving providers, members, and health plans, ensuring timely and accurate resolution of complex cases.
• Coordinates and manages multiple audit projects, ensuring deadlines and quality standards are met.
• Serves as a mentor and technical lead for Claims Auditors, providing guidance and training without direct supervisory authority.
• Coordinates team participation in special audits, ensuring consistency in methodology and reporting.

Education

High school diploma/GED required. Bachelor's degree in healthcare or related field highly preferred.

Experience

Five (5) years of professional and facility claims processing for Medicare and Commercial products, including high risk audits and provider dispute resolution required. Experience developing audit methodologies and SOPs required.

Two (2) years of Senior/Lead claims auditing experience in a medical claim's environment with demonstrated expertise in regulatory compliance and system testing required.