Claims Auditor – Medical Stop Loss

Skyward Specialty Insurance

Accident and Health Claims Auditor responsible for auditing and ensuring compliance of insurance claims. Collaborating with teams to enhance accuracy while training junior auditors and processors.

Posted 5/21/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $60,000 - $90,000 per yearWebsite

About the role

Key responsibilities & impact

Conduct thorough audits of accident and health insurance claims to verify accuracy, policy compliance, and proper adjudication.
Ensure claims adhere to company policies, industry regulations, and legal requirements, including HIPAA.
Analyze claims data to identify patterns, discrepancies, and opportunities for process improvement.
Prepare detailed audit reports and communicate findings, recommendations, and corrective actions to management and relevant departments.
Collaborate with claims processing teams to implement audit recommendations, streamline workflows, and enhance claims accuracy.
Serve as a subject matter expert by training junior auditors and claims processors on audit procedures and compliance standards.
Maintain accurate documentation of audit processes, findings, and follow-up actions, ensuring all information is safeguarded and confidential.
Stay updated on changing regulations, industry best practices, and emerging audit methodologies.

Requirements

What you’ll need

Bachelor’s degree in business, Insurance, or related field (preferred)
Minimum 3+ years in experience in medical claims auditing and processing in accidental and health insurance claims.
Robust knowledge of claims processing systems, protocols, and regulatory requirements.
Excellent analytical, problem-solving, and decision-making skills.
Strong attention to detail and organizational abilities.
Advanced knowledge of claims processing guidelines, medical terminology (ICD-10, CPT, HCPCS, UB04), and insurance concepts (UCR, COB, HIPAA, subrogation)
Familiarity with eligibility guidelines and group health plan administration (Medicare, COBRA, FMLA, etc.)
Strong analytical skills with attention to detail and proficiency in interpreting Plan Documents and reinsurance contracts.
Excellent written and verbal communication skills with proven customer service.
Effective problem-solving, team partnership, and project management abilities
Proficiency with claims processing systems and Microsoft Office Suite (Word, Excel, PowerPoint)

Benefits

Comp & perks

health and welfare benefits
tuition and professional certification assistance
401k savings
elective participation in the Employee Stock Purchase Program
paid time off
paid holidays
child bonding leave
employee assistance

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

medical claims auditingclaims processingdata analysisaudit proceduresmedical terminologyICD-10CPTHCPCSUB04insurance concepts

Soft Skills

analytical skillsproblem-solvingdecision-makingattention to detailorganizational abilitieswritten communicationverbal communicationcustomer serviceteam partnershipproject management