CLAIMS AUDITOR JOB DESCRIPTION

A Claims Auditor in managed care is someone who determines whether money that has already left a health plan should be returned. Accuracy at this level involves interpreting Medi-Cal and Medicare fee schedules, reading Delegation of Financial Risk (DOFR) agreements, and distinguishing billing errors from Fraud, Waste, and Abuse patterns. Each audit cycle produces recoverable dollars, corrective action plans, and provider report cards that feed directly into compliance reporting for CMS and state regulators. The role sits within the Claims or Compliance department and is accountable for audit closure rates, financial recovery totals, and the reliability of payment integrity data used by leadership.

As the Claims Auditor, you protect the financial and regulatory integrity of the health plan by identifying overpayments, verifying provider billing accuracy against Medi-Cal and Medicare guidelines, and delivering structured findings to Compliance and Provider Services. You operate within a managed care claims environment, coordinating across internal departments and external provider networks to close audit cycles within established turnaround and accuracy standards.

Career Impact: Sustained performance in this role builds recognized expertise in managed care payment integrity, a credential that holds significant market weight as Medicaid and Medicare auditing requirements continue to expand under CMS oversight.

Business Impact: When a claims audit cycle closes accurately, the health plan recovers overpaid funds, satisfies state and federal regulatory requirements, and gives Provider Services the data needed to issue corrective action plans that reduce future billing errors.

Growth Opportunity: The analytical and regulatory depth developed here opens a direct path toward senior audit roles, FWA investigation leadership, or Compliance program management within a managed care or health plan organization.

• Audit claims against Medi-Cal, Medicare, and commercial fee schedules to verify payment accuracy and identify overpayments.
• Read and interpret DOFRs and provider contracts to determine financial liability before adjudicating disputed amounts.
• Document audit findings, decision methodology, and monetary discrepancies in accurate, trackable records for financial reporting and trend analysis.
• Coordinate with the Recovery Department to initiate and advance overpayment recovery for confirmed discrepancies.
• Report Fraud, Waste, and Abuse indicators to the Compliance department and provide supporting documentation for further investigation.
• Provide structured feedback to Claims Management on billing errors, process improvement opportunities, and provider-level training needs.
• Validate corrective action plan implementation through follow-up audits to confirm that identified compliance deficiencies have been resolved.
• Compile periodic audit performance reports for internal departments including Provider Services, Contracting, and Compliance leadership.

• Bachelor's degree in Health Administration, Business, or a related field, or equivalent work experience.
• 3 or more years of claims processing or claims auditing experience, with demonstrated exposure to managed care, Medicaid, or Medicare environments.
• Working knowledge of Medi-Cal and CMS payment guidelines, including fee schedule interpretation and medical necessity criteria.
• Proficiency in reading and applying ICD-10 and CPT coding, medical terminology, and standard claims adjudication rules.
• Ability to read and interpret DOFRs, provider contracts, and delegation agreements to determine financial liability.
• Strong analytical and organizational skills, with demonstrated ability to manage multiple audit assignments and meet turnaround and accuracy standards simultaneously.
• Effective written and verbal communication skills, including the ability to present findings and recommendations to providers and internal stakeholders.

• Prior experience in a Fraud, Waste, and Abuse (FWA) auditing capacity within a health plan or managed care organization.
• Familiarity with Prospective Payment System methodologies, including APC and DRG grouping and pricing review.
• Experience coordinating vendor or third-party administrator audits, including pre-implementation reviews and post-onsite report drafting.
• Insurance or healthcare auditing designation such as Certified Professional Coder (CPC) or a comparable credential.

• Audit closure rate per cycle, measuring adherence to turnaround time standards across assigned caseload.
• Overpayment recovery dollars identified, reflecting the financial value of completed audit work per period.
• Audit accuracy rate, tracking the percentage of adjudication decisions that pass internal quality review without correction.
• Corrective action plan validation rate, measuring how consistently follow-up audits confirm provider compliance after remediation.
• Provider report card delivery timeliness, reflecting how reliably trending data reaches Provider Services within reporting windows.
• FWA referral accuracy rate, tracking the proportion of escalated cases substantiated upon Compliance department review.
• Typical tools: Claims adjudication platforms (commonly Facets or HealthEdge); data analysis (commonly Excel with large dataset manipulation).

• Base Salary Range: $55,000 to $80,000 annually, depending on experience and market
• Bonus: Annual performance bonus, typically 5 to 10% of base salary
• Equity: Generally not offered at this level in managed care settings
• Health Benefits: Medical, dental, and vision coverage; employer contribution standard
• PTO: 15 to 20 days annually, plus federal holidays
• Common Perks: Remote or hybrid audit work options, continuing education reimbursement for coding or compliance certifications

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Employment is contingent on successful completion of a background check, which may include verification of prior employment and criminal history consistent with applicable law. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state, or local law. Reasonable accommodations are available to individuals with disabilities throughout the application and employment process. Candidates must be authorized to work in the United States.

The Claims Auditor owns a portfolio of compliance audits across pharmacy, dental, and extended health lines, validating provider claims against contractual terms and conditions. Working alongside insurance companies, providers, and help desk teams, this role delivers accurate audit documentation and supports service level commitments that protect clients from billing errors.

Key Responsibilities

• Conduct various types of audits including desk, cardholder, on-site, compounds and mailers, and open-windows.
• Gather and compile data from multiple sources including providers, cardholders, physicians and dentists.
• Complete investigations and report on findings.
• Process adjustments and reversals on transactions as required.
• Maintain complete and accurate documentation of all audit-related information, reports and conversations.
• Manage multiple assignments at one time and provide backup support to other auditors.
• Provide basic technical support to insurance companies, providers, help desk, and other teams in client services.
• Contribute to achieving team objectives and delivery on service level commitments including all SLAs.

Required Qualifications

• High school diploma required; college diploma in health sciences or administration preferred.
• LOMA, CEBs, ICA or HIAA training is an asset.
• 1 to 3 years of experience in retail pharmacy, hospital pharmacy, dental or extended healthcare practice.
• Claims examiner experience is an asset.
• Knowledge of business flows in claims management and submission at a working level.
• Knowledge of pharmacy, dental, extended health and audit practices at a working level.
• Experience in Microsoft Office and network systems at an intermediate level.
• Ability to manage confidential information and protect privacy at an intermediate level.

Embedded within the compliance audit function, the Claims Auditor conducts third-party social compliance audits on behalf of customers and regional offices across labor, ethics, health and safety, and environmental standards. Working closely with buyers, regional offices, and workforce representatives, this role expands the customer database while ensuring auditee compliance with established certification and program requirements.

Core Functions

• Plan, schedule, and perform third-party compliance audits per requests from customers and regional offices.
• Collect and stay alert to relevant audit information, including applicable laws and industry profiles.
• Carry out instructions from regional offices and clients in accordance with client requirements and documented quality assurance procedures.
• Prepare and review audit reports with timely and accurate reporting to coordinating offices and clients.
• Market social compliance audits and expand the customer database.
• Undertake specific projects or special assignments as directed by management.
• Provide training and guidance to customers to achieve compliance standards where required.
• Represent the organization at buyer meetings, training sessions and workshops and share knowledge with team members.

Qualifications & Experience

• Degree or equivalent in a relevant field.
• Qualified lead auditor for RBA Labor and Ethics, Health and Safety, and Environment.
• APSCA CSCA or RA auditor certification.
• Qualification for other audit programs including SMETA, amfori and client code of conduct audits.
• Mandarin language proficiency required to conduct interviews with the Chinese workforce.

Reporting to claims management, the Claims Auditor reviews and audits medical stop loss claim submissions against plan documents, stop loss contracts, and carrier standards to ensure payment accuracy and regulatory compliance. Partnering with finance, third-party administrators, and cross-departmental teams, this role compiles periodic reporting and delivers the accuracy metrics that protect plan integrity.

Primary Duties

• Review and audit medical stop loss claim submissions against plan documents, stop loss contracts, and carrier standards.
• Facilitate financing of approved claims with the finance department.
• Pend claims and issue denials to third-party administrators where appropriate.
• Elevate complex claim issues for clinician or management review.
• Compile periodic reporting for internal and external parties and advise on claim projections and development.
• Recognize, document, and alert supervisors to trends in claims.
• Perform self-quality monitoring and execute plans to meet established goals and turnaround time and accuracy metrics.
• Collaborate cross-departmentally to improve or streamline procedures.

Skills & Qualifications

• High school diploma or GED required; Bachelor's degree in medical billing and coding or related field preferred.
• 5 or more years of experience in medical claims administration at a carrier or provider.
• Working knowledge of third-party administration functions preferred.
• Understanding of medical terminology required.
• Working knowledge of computers and Microsoft Office products.
• Strong organizational, problem-solving, and analytical skills with attention to detail.

Sitting at the intersection of dental billing and regulatory compliance, the Claims Auditor conducts clinical chart audits for affiliated dental providers to determine adherence to Medicaid and other payer requirements. Operating across provider accounts, insurance carriers, and the internal compliance team, this role maximizes office collections while ensuring conformance with local, state, and federal regulatory standards.

Duties

• Conduct clinical chart audits for affiliated dental providers to determine compliance with Medicaid and other payers.
• Read and analyze EOBs and make proper adjustments according to claims processing criteria.
• Send appeals to insurance carriers with justification for dental treatment payment.
• Audit accounts to ensure proper fees have been posted.
• Work with the compliance team to maximize office collections and minimize adjustments.
• Communicate issues and suggestions to improve processes.
• Ensure compliance with internal policies as well as state, federal, and other regulatory bodies.

Requirements

• Prior registered dental assistant experience.
• Prior dental billing experience.
• Experience with dental terminology and auditing.
• Understanding of local, state, and federal compliance regulations.
• Strong communication and organizational skills with close attention to detail.

A key member of the Compliance department, the Claims Auditor leads provider billing audits under the supervision of the Claims Oversight Supervisor to detect fraud, waste, and abuse and ensure the plan meets federal and state regulatory requirements. Collaborating across Provider Services, Contracting, and Recovery teams, this role delivers provider report cards and trending analysis that strengthen plan integrity and expand recovery opportunities.

Functions

• Audit claims to ensure providers are billing correctly.
• Provide feedback to providers for billing process improvement through provider report cards.
• Validate the effective implementation of corrective action plans through follow-up audits.
• Provide trending information to Provider Services and Contracting through reports and meetings.
• Report any possible fraud, waste, and abuse to the compliance department.
• Initiate and expand recovery opportunities by working with the Provider Resolution, Recovery, and Reconciliation and Reporting departments.
• Promote teamwork and maintain effective working relationships throughout the organization.

Qualifications & Experience

• 4 years of experience auditing claims in a managed care environment, including contract and financial DOFR interpretation.
• 2 years of claims processing experience including Medi-Cal and Medicare.
• Knowledge of Medi-Cal and CMS guidelines for claim payments.
• Ability to manipulate large data sets in Microsoft Excel.
• Strong analytical, problem-solving, and written and verbal communication skills.

Accurate compliance and contractual audit outcomes across claims, enrollments, and customer service depend on the Claims Auditor, who performs audits covering MTM, FEP, Performance Guarantee, and LDLA programs to ensure adherence to specifications, quality standards, and contractual agreements. Based within an audit operations function, this role identifies findings, drafts operational communications, and participates in corrective and preventive action planning.

Accountabilities

• Perform compliance and contractual audits across claims, customer service, enrollments, and related areas.
• Identify and accurately document observations and findings.
• Draft communications to operations regarding audit observations and findings.
• Research and respond to rebuttals.
• Participate in corrective and preventive action planning and implementation.

Experience & Qualifications

• Excellent PC skills including Microsoft Office.
• Strong organizational skills, attention to detail, and analytical skills with strong reading comprehension.
• Ability to objectively review and interpret standards, procedural documentation, and contract and legal language.
• Ability to access information and organizational references necessary to complete tasks.
• Strong written and verbal communication skills.

As the Claims Auditor, this role reviews estimates from shops and independent appraisers to evaluate accuracy against accepted industry repair standards, including writing total loss and repair estimates from photos and negotiating agreed repair costs. The material damage team relies on this work to maintain claim service standards, ensure fair claims practice compliance, and resolve customer concerns efficiently.

Job Functions

• Review estimates from shops and independent appraisers to evaluate accuracy against accepted industry repair standards.
• Revise estimates as necessary and negotiate agreed repair costs with shops where applicable.
• Write repair and total loss estimates from photos when required.
• Evaluate supplements from shops or independent appraisers and secure appropriate support.
• Determine reparability versus total loss and review subrogation demands for accuracy.
• Provide technical guidance and assist with training for material damage adjusters.
• Maintain reports of estimates reviewed and document changes made from original estimates.
• Maintain claim service standards to ensure compliance with fair claims practices and resolve customer concerns.

Professional Experience

• I-CAR training and certification preferred.
• Minimum 2 years of experience as a claims field appraiser or in a similar role with DRP management experience.
• Experience with auto estimating and auditing platforms, preferably CCC.
• Demonstrated negotiation and problem-solving skills.
• Strong customer service, organizational, and communication skills.
• Ability to work under pressure.

Claims Auditor delivers accurate review and interpretation of stop loss claim submissions for disclosure and accuracy before carrier submission, including daily maintenance of claims and payment logs and monthly loss ratio reporting. The work directly supports carriers, administrators, and sales staff by ensuring claim amounts, denials, and plan document appeals are resolved with precision and communicated on time.

What You'll Do

• Review and interpret stop loss claim submissions for disclosure and accuracy before carrier submission.
• Determine if claim amounts are correct and decide if claims need to be challenged.
• Communicate timely with carriers or administrators regarding additional information needed to process claims.
• Review claim payments and denials for accuracy before communication to the administrator.
• Review client plan documents to assist in appeals of claim denials where applicable.
• Assist sales staff with monthly renewal claim reporting as needed.
• Maintain and analyze the claims and payment log daily and update the loss ratio report monthly.

Minimum Qualifications

• High school diploma or equivalent required.
• Minimum 3 years of related claims experience required.
• Strong working knowledge of reinsurance and claims processing.
• Strong understanding of CPT, ICD-9, HCPCS, medical terminology, COB, COBRA, and FMLA.
• Strong knowledge of Microsoft Office including Excel, Word, and Outlook.
• Proficiency in web browsers.
• Good written and verbal communication skills.

The Claims Auditor produces thorough audits of high-dollar healthcare claims while maintaining acceptable inventory levels and independently interpreting medical policy and clinical guidelines as a subject matter expert. Working within a quality audit team in a healthcare or insurance environment, this role identifies coding and processing errors, mentors audit staff, and enables financial reporting and trending analysis that improve claims accuracy across the organization.

Day-to-Day Responsibilities

• Perform audits of and adjudicate high-dollar claims while maintaining acceptable levels of claims inventory and age.
• Verify claim payment accuracy including eligibility, system coding and pricing, pre-authorization, and medical necessity.
• Complete and maintain detailed documentation of audit decisions, system or processing errors, and monetary discrepancies for financial reporting and trending analysis.
• Provide feedback on claims processing errors and identify quality improvement opportunities.
• Initiate system requests related to coding or processing issues and refer overpayment opportunities to the recovery team.
• Independently interpret medical policy and clinical guidelines and serve as subject matter expert for policy and clinical guidelines.
• Mentor and serve as a resource to other audit staff.

Background & Experience

• High school diploma or GED required, bachelor's degree or RN preferred.
• 4 to 5 or more years of claims processing experience, including at least 1 year in a quality audit capacity in healthcare or insurance.
• Working knowledge of the insurance industry and medical terminology.
• Detailed knowledge of claims processing systems, principles, techniques, and guidelines.
• Ability to acquire and perform progressively more complex skills and tasks in a production environment.
• Strong research and problem-solving skills.

Embedded within the Operations Audit team, the Claims Auditor leads and assists in insurance operations reviews of programs and services offices, evaluating adherence to underwriting and claim authority, compliance with insurance regulations, and implementation of operational best practices. Working closely with legal, regional profit center leaders, and business unit personnel, this role advances audit quality through in-depth research and delivers findings that drive operational improvements across brokerage and retail channels.

Scope of Work

• Lead and assist in insurance operations reviews of programs and services offices, including brokerage and retail reviews as needed.
• Conduct in-depth research on specialized business operations to ensure optimal review outcomes.
• Participate in follow-up reviews for profit centers requiring additional consultation.
• Submit reports and responses to the legal department for each office reviewed.
• Stay informed of industry developments through trade publications, related manuals, and meeting participation.
• Participate in annual departmental planning and other meetings and perform other duties as assigned by leadership.

Technical Qualifications

• 4-year college degree required; insurance certificates and designations beneficial.
• 2 or more years of property and casualty insurance carrier, brokerage, or agency experience, with background in underwriting or claims preferred.
• Knowledge of multiple insurance lines is a plus.
• Proficiency in Microsoft Office Suite with ability to quickly learn new programs and agency management systems.
• Strong written and oral communication skills.
• Demonstrated ability to present findings to leaders across profit centers.
• High degree of self-motivation, discipline, and professional appearance required.
• Willing to travel 30 to 40 percent of the time.
• Must hold a valid driver's license.

Reporting to claims management, the Claims Auditor develops accurate prospective and retrospective audits of claims adjudicated by the system and Claims Examiners, using auditing tools to interpret DOFRs, provider contracts, and Medi-Cal and Medicare fee schedules. Partnering with internal departments and the recovery team, this role delivers trending documentation, process improvement feedback, and coordination on overpayment remediation that strengthens compliance across managed care operations.

Core Responsibilities

• Audit claims in accordance with applicable federal and state regulations based on the member's line of business.
• Read and interpret DOFRs to ensure the group is financially at risk for payment.
• Read and interpret provider contracts and Medi-Cal and Medicare fee schedules to ensure payment accuracy.
• Utilize auditing tools to identify and determine the accuracy of claims payments both prospectively and retrospectively.
• Coordinate with internal departments on issues relating to provider, fee schedule, eligibility, authorization, or system matters.
• Complete documentation for tracking and trending of data to identify system issues and remediation needs.
• Provide regular feedback to claims management on process improvement and training opportunities.
• Coordinate with the recovery department for any identified overpayments.

Knowledge Skills & Abilities

• 3 or more years of claims processing experience.
• Knowledge of Medi-Cal regulations required, with preferred knowledge of Medicare and commercial rules.
• Knowledge of medical terminology and managed care concepts required.
• Ability to read and interpret DOFRs and provider contracts.
• Strong organizational, mathematical, and analytical skills.
• Ability to establish and maintain effective work relationships with coworkers, clients, members, providers and customers.

Sitting at the intersection of health claims adjudication and vendor audit management, the Claims Auditor leads team processes through vendor claims audits, re-adjudicating claims, resolving discrepancy issues identified by field auditors, and drafting final audit reports. Operating across client plan types including consumer-driven, PPO, indemnity, and managed care, this role manages individual claim distribution, develops vendor relationships, and contributes to new tools and approaches that raise audit quality.

Leadership Responsibilities

• Conduct pre-implementation audits and accurately document all audit findings.
• Review client plans and brief the team on unique provisions and issues before onsite audits.
• Adjust workloads as necessary to ensure successful project completion.
• Review documentation of potential discrepancies for thoroughness and accuracy and resolve post-onsite audit activities in a timely manner.
• Write quality draft reports and participate in client presentations of findings when requested.
• Develop working relationships with vendor counterparts and manage individual claim and work queue distribution to the team.
• Ensure professional excellence protocols are followed throughout the audit process.

Position Requirements

• 3 or more years of experience in health claims adjudication, preferably in a consulting or major insurance claims administrator or health plan environment.
• Familiarity with all plan types including consumer-driven, PPO, indemnity and managed care.
• Experience covering medical, dental, mental health and Medicare.
• Detailed knowledge of ICD-10 and CPT codes and coding protocols.
• Solid understanding of health and welfare plan design and vendor processes and operating environments.
• Excellent oral and written communication skills.
• Strong work ethic and ability to work independently.
• Ability to travel approximately 25% of the time.

A key member of the claims quality function, the Claims Auditor conducts monthly audits of health plan claims utilizing federal, state, and internal guidelines to ensure processing accuracy and regulatory compliance. Collaborating across health plan departments and management, this role analyzes prospective payment system grouping, prepares management summaries, and identifies workflow enhancements that improve claim accuracy at a Medicaid or Medicare health plan.

Strategic Responsibilities

• Conduct monthly audits of claims utilizing applicable guidelines, policies, procedures, and regulatory requirements.
• Follow defined audit processes and stay current with departmental changes in conducting quality reviews.
• Ensure consistent use of current codes, correct documentation, and departmental procedures by monitoring and identifying deficiencies.
• Prepare management summaries of quality review results including basic trend analysis.
• Analyze audit results to recommend system or procedural changes to increase claim accuracy and identify workflow enhancement opportunities.
• Evaluate prospective payment system grouping and pricing information, including APC and DRG.
• Provide expertise on provider billing and payment guidelines consistent with internal policies and state or CMS guidelines.

Education & Experience

• Bachelor's degree in a financial field or equivalent healthcare experience.
• 2 or more years of claim processing experience with a Medicaid or Medicare health plan.
• Proficiency with Microsoft Office applications including Word, Excel, and Outlook.
• Strong organizational, analytical, and writing skills with attention to detail and effective presentation skills.
• Strong verbal and written communication skills with ability to engage all levels of management.
• Service-oriented team player with ability to multi-task and appreciate cultural diversity.

Sustaining accurate and timely reinsurance claims outcomes depends on the Claims Auditor, who leads cedent claims audits for domestic and international accounts, reviewing coverage applications, liability, damage assessments, and financial reserving activity. Serving as the primary audit resource for cedent claims leadership and the reinsurance claims director, this role develops training, delivers data analytics and dashboards, and ensures open file reviews are completed on an annual basis.

Ownership Areas

• Lead reinsurance cedent claims audits for domestic and international accounts.
• Review cedent claims processes to ensure proper identification and application of coverage, liability and damage assessments.
• Evaluate cedent financial claims activity to ensure accurate and timely reserving, recovery potential, and payments.
• Report audit results to cedent claims leadership and make recommendations on necessary training.
• Develop and deliver training sessions as requested by cedents.
• Conduct quarterly reinsurance claims audits by reviewing files above adjuster authority level.
• Create and provide reports from internal and external auditing activity to the reinsurance claims director and complete an annual review of all open files.

Education & Experience

• Bachelor's degree in business administration, insurance, or related field or equivalent work experience.
• 8 years of experience in reinsurance or property and casualty insurance claims adjusting, including auditing and training.
• Insurance designation such as AIC, ARe or CPCU preferred.
• Strong knowledge of insurance policies, claims philosophy, procedures and terminology, including awareness of industry trends.
• Ability to create data analytics and dashboards and manipulate large data sets in Excel.
• Excellent written and verbal communication skills with the ability to present to multiple leadership levels.
• Willing to travel domestically and internationally.
• A valid driver's license required.

As the Claims Auditor, this role reviews and audits healthcare claims to determine Medicare and commercial primacy, closing a required daily audit volume at 100% quality while investigating overpaid or incorrectly paid claims and initiating recovery on behalf of clients. The claims recovery team relies on this work to maximize overpayment identification through research in client claims systems, internet resources, and direct communication with providers, employers, members, and Medicare representatives.

Delivery Expectations

• Review and audit healthcare claims to determine Medicare and commercial primacy by investigating known indicators and communicating with providers, employers, members, and Medicare representatives.
• Utilize all available resources to maximize identification and recovery of overpayments in compliance with company policies and state and federal laws.
• Perform administrative tasks required for the invoicing and recovery process.
• Create and maintain files with all appropriate documentation to clearly identify an audit trail for each audit performed.
• Close files in accordance with required coding and approvals per division guidelines.
• Communicate with team management regarding training needs, job knowledge issues, or other concerns.
• Seek to identify process improvements to increase the value of service provided to clients.

Qualifications & Experience

• Associate's degree required, Bachelor's degree preferred, or equivalent experience in health insurance or related fields.
• Experience in the healthcare or insurance field is helpful.
• Proficiency in Microsoft Word, Excel, and Outlook with a typing speed of at least 30 words per minute.
• Strong analytical, organizational, and time management skills with proven attention to detail.
• Ability to work independently and maintain confidentiality.
• Demonstrate integrity and professionalism in all communications.
• Spanish or bilingual proficiency is a plus.

Claims Auditor refines the end-to-end process of managing and reviewing transportation and carrier claims from filing to resolution, determining maximum carrier liability and issuing payments to customers within defined time standards. The work directly supports the Accounting team and carrier and customer representatives by maintaining accurate claims and credit tracking spreadsheets and ensuring proper coverage verification with the trade insurance company.

Areas of Ownership

• Process assigned claims from filing to resolution accurately and within time standards.
• Review claim documents for accuracy and research evidence to make informed decisions on appeals, declinations, and payment requests.
• Issue payments to customers and process deductions for carriers.
• Communicate with carriers, insurance companies, and customers to provide status updates, request additional information, and resolve concerns.
• Maintain and update the claims tracking spreadsheet and credit and balance tracking spreadsheet to meet aging time standards.
• Verify and approve credit based on credit SOP and confirm accounting contacts and billing methods are set up appropriately.
• Work with the trade insurance company to ensure proper coverage and accuracy.

Required Qualifications

• High school diploma or GED equivalent required.
• Experience in transportation, shipping, or sales in a 3PL environment preferred.
• Proven ability to process claims generally up to $5,000.
• Strong critical thinking, judgment, and decision-making skills, with attention to detail.
• Good written and verbal communication skills.
• Strong risk analysis and organizational skills.

The Claims Auditor creates comprehensive file reviews and audits of program third-party administrators, analyzing caseload assignments and presenting findings on facts, trends, and prognosis to leadership in roundtable discussions. Collaborating with Program Underwriting, Claims teams, and external TPAs, this role negotiates settlements, manages litigated files, and ensures state claims handling requirements and internal guidelines are met across all program assignments.

Role Responsibilities

• Perform file reviews and audits of program third-party administrators.
• Analyze all claims assignments and present findings in roundtable discussions to leadership, including facts, trends, and prognosis.
• Investigate allegations and determine facts based on evidence and interviews of relevant parties.
• Draft disclaimers and reservation of rights letters as soon as coverage issues are identified.
• Assign task-based investigations to independent licensed insurance professionals.
• Negotiate settlements, mitigate losses, and control expenses within authority.
• Manage litigated files per litigation management guidelines and refer matters to defense or coverage counsel with manager approval.
• Maintain high-level communication with internal and external stakeholders, including TPAs and program administrators.

Skills & Qualifications

• High school diploma required, bachelor's degree preferred.
• Adjuster license and certifications preferred.
• Minimum 3 years of claims handling experience.
• Experience with liability coverage issues required.
• Minimum 1 year of multi-jurisdictional claims experience required.
• Thorough knowledge of claims and litigation management processes.
• Proficiency in Microsoft Office including Word, Excel, and Outlook.
• Strong analytical skills.
• Strong written and verbal communication and negotiation skills with the ability to communicate effectively at all levels of the organization.