Auditor

• Perform auditing of claims, ensuring processing, payment, and financial accuracy by verifying all aspects of the claim have been handled correctly and according to both standard process and the client’s summary plan description.
• Completes reporting of audits finalized with decision methodology for procedural and monetary errors, which are used for quality reporting and trending analysis utilizing QA tools.
• Responsible to communicate corrections and adjustments to Examiners as identified on pre-payment audits, including high dollar claims, and to verify corrections and adjustments are complete and accurate.
• Identify and escalate trends based on the quality reviews.
• Confer with Claims QA Lead, Claims Supervisors, Claim Managers, and/or Training Lead on any problematic issues warranting immediate corrective action.
• May investigate and research issues as required to create or improve standard processing guidelines and may participate in projects as a subject matter expert as needed.
• Perform any other additional tasks as necessary, including processing of claims, creating policies, training, and/or mentoring examiners through quality improvement plans.

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