Health Plan Claims Auditor
Health Plan Claims Auditor
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Job Description
SUMMARY
Curative is seeking a highly skilled Health Plan Claims Auditor to lead auditing activities within our claims operations team. As a Health Insurance Claims Auditor youll ensure the accuracy compliance and quality of our claims operations by designing rigorous sampling plans dissecting audit results and empowering teams through targeted coaching. Youll be a driving force behind continuous improvementcombining quality assurance insights with outcome-based mentorship. This role focuses on ensuring payment accuracy compliance with regulatory requirements contractual obligations and internal policies. The ideal candidate will bring deep expertise in healthcare claims auditingspanning hospital facility professional and behavioral health claimswith strong experience in claims adjudication systems. Experience with HealthEdge HealthRules Payer is highly preferred. You will leverage analytical skills and knowledge of claims adjudication processes to identify trends prevent errors and support quality improvement initiatives. The successful candidate will be a self- starter who thrives in a dynamic environment and can work independently while collaborating cross- functionally with claims operations configuration compliance and finance teams.
Note: Finalist candidates may be asked to complete a practical exercise to showcase their claims
auditing skillset.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Develop and execute audit sampling methodologies (stratified systematic random) to select representative claim populations.
- Perform in-depth audits of complex medical hospital facility professional and behavioral health claims to ensure compliance with:
- Regulatory requirements (state prompt pay laws HIPAA CMS)
- Provider contract terms and benefit plan designs
- Internal policies and procedures
- Leverage HealthEdge HealthRules Payer platform functionality to review adjudication logic validate configuration accuracy and troubleshoot claims processing issues.
- Identify error trends and root causes developing actionable recommendations to improve claims processing accuracy and reduce operational risk.
- Collaborate with configuration claims operations provider relations and compliance teams to remediate identified audit findings and implement corrective actions.
- Create and maintain audit tracking tools and dashboards to monitor error rates financial impact and audit outcomes (e.g. SQL Excel Power BI Tableau or Looker).
- Participate in pre- and post-implementation audits for system changes new product launches and benefit updates to ensure system readiness and accurate claims adjudication.
- Design and deliver coaching sessionsgroup workshops one-on-one feedback and refresher trainingto lift accuracy and adherence.
- Act as a subject matter expert for claims accuracy providing training and guidance to claims processors and analysts as needed.
- Prepare clear data-driven audit reports with metrics visualizations and actionable recommendations.
- Prepare and present executive-level reports summarizing audit findings trends and recommendations for operational improvement.
- Support regulatory or client-driven audits ensuring accurate and timely response to external requests for information.
- Stay current on healthcare regulations (HIPAA ICD-10/CPT coding) payer guidelines and industry best practices.
- Adhere to all Curative policies promoting a culture of compliance accuracy and accountability.
- Perform special projects audits or analytical initiatives as assigned.
- Provide backup and support for other audit functions as needed.
QUALIFICATIONS
- Strong understanding of healthcare reimbursement methodologies (DRG APC RBRVS bundled payments).
- Ability to identify systemic issues and develop solutions that improve operational accuracy and efficiency.
- Skilled in interpreting payer contracts and benefit plan designs.
- Experience leveraging dashboards and visual reports (Power BI Tableau Looker).
- Proven ability to coach and mentor staff to elevate performance and compliance.
- Strong analytical mindset with exceptional attention to detail.
- Excellent verbal and written communication skills capable of influencing stakeholders.
- High attention to detail with the ability to meet deadlines and manage multiple audit initiatives simultaneously.
- Proficiency in Google Workspace (Docs Sheets Slides Forms).
Preferred Skills:
- HealthEdge HealthRules Payer platform configuration and auditing experience (strongly preferred).
- Familiarity with Lean Six Sigma or other continuous improvement methodologies.
- Experience supporting or leading external regulatory audits and payer financial recoveries.
- Familiarity with claims data mining tools or scripting languages (e.g. Python) for advanced audit
analytics.
EDUCATION and/or EXPERIENCE
- Bachelors degree in Healthcare Administration Business Finance or related field required. (Masters degree in Healthcare Management Data Analytics or MBA preferred.)
- 3-5 years of health insurance claims auditing experience (hospital facility professional and behavioral health claims).
- Demonstrated experience auditing within complex claims environments including configuration and benefit interpretation.
- Strong analytical and problem-solving skills with experience utilizing SQL Excel (pivot tables Power Query) and data visualization tools (Power BI Tableau Looker).
- Knowledge of CPT HCPCS ICD-10 revenue codes and medical terminology.
- In-depth understanding of state prompt payment regulations and federal healthcare laws (HIPAA ACA CMS).
- Proven ability to prepare detailed audit reports and present findings to senior leadership.
- Excellent interpersonal and written communication skills with the ability to work collaboratively across teams and effectively manage competing priorities.
WORK ENVIRONMENT
- While performing the duties of this Job the employee is regularly required to sit; use hands to handle or
feel; talk; and hear. - Specific vision abilities required by this job include close vision distance vision color vision peripheral vision depth perception and ability to adjust focus.
- The noise level in the work environment is usually: Mild
- For this position the percentage of expected Travel is: 10 % of the time
Required Experience:
IC
Employment Type
Full-Time
