Claims Audit Specialist

Role Impact:

-, Ensures accuracy and compliance by auditing complex Medicare and Medi-Cal claims, directly impacting financial integrity and provider trust.

• Plays a key role in identifying trends, mitigating risk, and driving process improvements to strengthen system performance and reduce errors.

Day-to-Day Responsibilities:

• Review processed claims for accuracy while maintaining acceptable levels of aged claims inventory.
• Verify claim form aspects including eligibility, configuration, payment accuracy, provider records, and compliance requirements.
• Maintain detailed audit documentation and provide feedback on errors and improvement opportunities.

Requirements and Qualifications:

• Bachelor’s degree or equivalent professional experience with minimum five years in Medicare/Medicaid claims processing and auditing.
• Proficient in Microsoft Excel with working knowledge of CPT/HCPCS codes, ICD-10 codes, and federal/state regulations.
• Strong organizational, analytical, communication, and time management skills, and experience with CMS and Medi-Cal claims.