Specific Claims Auditor

Accountabilities

• • 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.
  • Maintain accurate, confidential claim records and apply established procedures, policies, and quality standards consistently.
  • Stay informed about relevant industry developments, legal requirements, and technical changes that may affect claims administration and insurance operations.

  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 when interacting with clients and third-party administrators.
  • 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.

  Benefits

  • Competitive salary range of $40,300–$80,800, with geographic adjustments where applicable.
  • Remote work opportunity within the United States, including eligibility for remote work from Georgia as specified in the original posting.
  • Generous paid time off and 12 paid company holidays.
  • 401(k) retirement plan with a 6% company match.
  • Health and dental insurance, plus vision coverage.
  • Company-provided long-term disability and life insurance.
  • Paid parental leave and volunteer time off.
  • Flexible work schedules designed to support work-life balance.
  • Opportunities for professional advancement within a successful and growing organization.
  • Additional workplace perks, including a casual work environment and modern office facilities where applicable.
  • Compensation may vary based on geographic location, qualifications, experience, education, skills, and other applicable factors.