Claims Auditor

Job Summary

A company is looking for an Auditor, Delegate Claims.

Key Responsibilities

• Conduct detailed claims audits to ensure compliance with regulatory and contractual requirements
• Engage with delegated provider organizations to correct deficiencies and improve performance
• Validate the effectiveness of Corrective Action Plans (CAPs) and report audit findings for organizational awareness

Required Qualifications

• 3-5 years of claims experience in an HMO, Medicare Advantage, and/or IPA setting
• Prior experience in conducting oversight audits of delegated entities and/or ancillary providers
• Demonstrable knowledge of CMS claims compliance reporting
• High school diploma required; Bachelor's degree preferred
• Strong knowledge of Medicare audit processes and applicable regulatory requirements