Claims Auditor

Claims Audit Specialist

Provides support for claims audit activities including identification of incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and claims processing errors.

Essential Job Duties

• Audits the adjudication of claims using standard principles, and state-specific regulations to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing of claims errors.
• Prepares, tracks and provides claims audit findings reports according to established timelines.
• Presents claims audit findings and makes recommendations to leadership for improvements based on audit results.
• Reviews timeliness of claims processing to ensure compliance with contractual and state/federal requirements.
• Maintains minimum claims audit accuracy rate per contractual guidelines.
• Supports claims department initiatives to improve overall claims function efficiency.
• Meets claims audit department quality and production standards.
• Completes basic claims projects as assigned.
• Experience in reviewing high $ claims, claims payment method.

Required Qualifications

• At least 2 years of experience in a clerical role in a claims, and/or customer service setting - preferably in managed care.
• Audit, research, and data entry skills.
• Organizational skills and attention to detail.
• Time-management skills, and ability to manage simultaneous projects and tasks to meet internal deadlines.
• Customer service experience.
• Effective verbal and written communication skills.
• Microsoft Office suite and applicable software programs proficiency.

Preferred Qualifications

• Health care claims auditing/billing experience.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V