Claims Auditor

Prime Therapeutics

Our work matters. We help people get the medicine they need to feel better and live well. We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Description Summary

This position supports management in the design, implementation, and maintenance of claims auditing programs. Responsible for auditing claims for accuracy. Verify that claims are being adjudicated according to Magellan contracts in a consistent and accurate manner. Work closely with claims department to report issues and determine resolutions.

Job Description

• Reviews benefit plans to ensure that claims are being adjudicated accurately and consistently according to Magellan contracts. Audits claims for financial accuracy.
• Responsible for documenting and reporting issues found.
• Assists with the establishment and updating of processes and audit manuals.
• Identifies areas where issues exist and works with appropriate individuals to ensure resolution
• Completes special focused audits as assigned by management.
• Trains and mentors new auditors; works with trainers to audit and develop trainees.
• Act as a resource for the auditing team.

Responsibilities

• An understanding of contracts, business and insurance principals related to claims adjudication.
• Requires ability to read and understand benefit plans.
• Experience with multiple claim processing systems.
• Knowledge of coordination of benefit guidelines.
• An understanding of the adjustment and resolution process.
• Good interpersonal skills.
• Must function independently with strong organizational skills.
• Ability to handle multiple accounts and priorities.
• Strong verbal and written communication skills.
• Minimum 1 year health claims audit experience.

• An understanding of the Magellan contracts, business and insurance principles related to claims adjudication.
• Experience with Magellan’s multiple claim processing systems.

Work Experience

Work Experience – Required: Claims

Education

Education – Required: GED, High School

Potential pay for this position ranges from $18.50 – $27.75 based on experience and skills. Pay range may vary by 8% depending on applicant location.

Prime Therapeutics LLC is an Equal Opportunity Employer. We encourage diverse candidates to apply and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender identity or expression, genetic information, marital status, family status, national origin, age, disability, veteran status, or any other legally protected class under federal, state, or local law.

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