Specific Claims Auditor in New York at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Specific Claims Auditor based in United States.

This role is responsible for reviewing and auditing individual claims to determine liability accurately and efficiently.
You will interpret health coverage plans and excess insurance policies to validate claim payments and coverage decisions.
The position combines medical knowledge, analytical review, financial judgment, and careful documentation.
You will work with third-party administrators and clients to resolve claim-processing questions and ensure accurate outcomes.
The role also involves establishing and maintaining appropriate claims reserves and authorizing payments within policy limits.
You’ll collaborate with claims and case management teams on significant claims and specific diagnoses requiring additional attention.
This is an opportunity to contribute to a specialized insurance environment where accuracy, confidentiality, and sound judgment directly support quality claims management.

• Review and interpret employer health plans, excess insurance policies, claim reports, and related documentation to determine individual claim liability.
• Audit submitted claim information for completeness and accuracy, verifying that benefits have been paid appropriately and in accordance with applicable plans, contracts, and policies.
• Investigate claim details and determine the extent of coverage and financial liability within established departmental standards and timelines.
• Communicate with third-party administrators and clients by phone and in writing to clarify information, resolve processing issues, and explain coverage decisions.
• Establish claim reserves based on anticipated liability and adjust reserves as necessary to keep them accurate and current.
• Authorize claim payments within the applicable liability limits and communicate the rationale for amounts that are not covered under the excess policy.
• Escalate large-dollar claims and claims involving trigger diagnoses to preliminary claims and case management teams for further review.
• Maintain accurate, confidential claim records and apply established procedures, policies, and quality standards consistently.
• Stay informed about relevant industry developments, legal requirements, and technical changes that may affect claims administration and insurance operations.

• Strong medical knowledge, including ICD, CPT, medical terminology, COBRA, HIPAA, and related healthcare and insurance concepts.
• Ability to read, interpret, and apply health plan documents, benefit provisions, claim reports, procedural manuals, and insurance policies.
• Demonstrated understanding of claims administration principles, practices, procedures, and liability assessment.
• Strong analytical and organizational skills, with the ability to manage multiple claims, priorities, and deadlines accurately.
• Excellent written and verbal communication skills, with a professional approach to confidentiality, tact, and diplomacy when interacting with clients and third-party administrators.
• Ability to exercise sound judgment when reviewing claim documentation, determining liability, establishing reserves, and escalating issues.
• Intermediate proficiency with Microsoft Office, including Excel, Access, PowerPoint, and Word.
• Ability to stay current with industry changes, legal updates, and technical developments relevant to healthcare claims and specialty insurance.
• Strong attention to detail and the ability to work independently while following established policies, procedures, and departmental standards.

• Competitive salary range of $40,300–$80,800, with geographic adjustments where applicable.
• Remote work opportunity within the United States, including eligibility for remote work from Georgia as specified in the original posting.
• Generous paid time off and 12 paid company holidays.
• 401(k) retirement plan with a 6% company match.
• Health and dental insurance, plus vision coverage.
• Company-provided long-term disability and life insurance.
• Paid parental leave and volunteer time off.
• Flexible work schedules designed to support work-life balance.
• Opportunities for professional advancement within a successful and growing organization.
• Additional workplace perks, including a casual work environment and modern office facilities where applicable.
• Compensation may vary based on geographic location, qualifications, experience, education, skills, and other applicable factors.