Claims Auditor (Remote - WI or MN)

📋 Description

• • Be the guardian of accuracy and compliance for Security Health Plan’s claims operations. As a Claims Auditor you will conduct end-to-end audits of medical, dental, vision and pharmacy claims to verify payment accuracy, procedural correctness, turnaround-time adherence and regulatory compliance. Your findings directly protect millions of dollars in healthcare spend and safeguard member trust.
• • Design and execute risk-based audit plans that target high-dollar, high-volume and error-prone claim categories. You will pull data from Facets, SQL and Excel, stratify populations, define sample sizes and apply statistical and judgmental sampling techniques to ensure every audit is both efficient and defensible.
• • Perform deep-dive claim reviews by interpreting CPT, HCPCS, ICD-10 and DRG codes against provider contracts, medical policies and state/federal mandates. You will validate coding accuracy, pricing logic, authorization requirements, coordination-of-benefits rules and discount applications, documenting every discrepancy with clear evidence and root-cause analysis.
• • Partner with Claims Operations leadership to translate audit results into actionable process improvements. You will present concise, visually compelling reports that highlight error trends, financial impact and compliance gaps, then collaborate on corrective action plans, workflow redesign and staff education initiatives.
• • Monitor post-implementation effectiveness by re-auditing previously flagged areas, tracking key performance indicators (KPIs) such as first-pass yield, auto-adjudication rates and appeal overturn ratios. Your continuous feedback loop ensures sustainable quality gains and supports NCQA, CMS and state regulatory readiness.
• • Serve as the subject-matter expert for complex claim inquiries from member services, provider relations and appeals teams. You will provide authoritative coding guidance, interpret contract language and recommend fair and defensible resolutions that balance cost containment with exceptional member experience.
• • Champion a culture of compliance by developing and delivering targeted training for claims examiners, coders and new hires. You will create quick-reference guides, lunch-and-learn sessions and e-learning modules that reinforce correct coding principles, policy updates and audit lessons learned.
• • Leverage advanced analytics to proactively identify emerging fraud, waste and abuse patterns. You will mine claim data for outliers, run predictive models and coordinate with the Special Investigations Unit to initiate focused audits that recover inappropriate payments and deter future misconduct.
• • Maintain meticulous audit documentation in accordance with HIPAA, CMS, OIG and state retention requirements. You will ensure every work paper, email and report is version-controlled, time-stamped and stored securely to withstand internal, external and regulatory scrutiny.
• • Work fully remote from Wisconsin or Minnesota while staying seamlessly connected to a collaborative, high-performing team. You will participate in daily huddles, weekly calibration sessions and monthly cross-functional forums that foster innovation, celebrate wins and keep everyone aligned to our mission of accessible, affordable and compassionate healthcare.