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Claim auditor skills for your resume and career

Updated January 8, 2025
3 min read
Below we've compiled a list of the most critical claim auditor skills. We ranked the top skills for claim auditors based on the percentage of resumes they appeared on. For example, 9.1% of claim auditor resumes contained medical terminology as a skill. Continue reading to find out what skills a claim auditor needs to be successful in the workplace.

15 claim auditor skills for your resume and career

1. Medical Terminology

Here's how claim auditors use medical terminology:
  • Required extensive knowledge of medical terminology and coding.
  • Applied extensive knowledge of contracts, contract language and medical terminology.

2. Medicaid

Here's how claim auditors use medicaid:
  • Researched Medicaid State reimbursement regulations for claim payment compliance reviews and documentation to support audit findings.
  • Contracted with Lovelace Medicaid to provide transportation for Medicaid Salad members in accordance with Medicaid guidelines.

3. Patients

Here's how claim auditors use patients:
  • Contacted self care patients to set up payment plans for services rendered as wee as working AR reports past 90 days.
  • Received and returned telephone calls to and from patients, providers, facilities and related entities that requested certification reviews.

4. HCPCS

Here's how claim auditors use hcpcs:
  • Analyze medical records for consistency and completeness using ICD-9, CPT-4 and HCPCS Level II established criteria and regulations.
  • Verify all member and provider information is correct and also make sure all HCPCS codes are correct

5. CMS

A Content Management System or CMS is computer software that works as a framework where content can be assembled and managed by using a database. CMS is an important asset in web development. This platform enables users to create, edit, collaborate on, publish and store digital content. It helps users to manage their content and modify it from a single system.

Here's how claim auditors use cms:
  • Reviewed patient records to maintain that HCC documentation guidelines designated by CMS were followed by providers.
  • Coordinate and manage all external audits by Health Plans, CMS or Department of Insurance.

6. Audit Findings

Here's how claim auditors use audit findings:
  • Analyzed and validated audit findings according to payer regulations and payer processing guidelines / provider contracts.
  • Document and trend audit findings and recommends quality improvement measures.

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7. Medical Claims

Here's how claim auditors use medical claims:
  • Evaluated and audited medical claims for different companies using various automated systems to detect procedural and monetary errors.
  • Communicated effectively with multiple departments to discuss financial aspects of the medical claims.

8. Process Claims

Process claims refers to the procedure an insurance agent follows once receiving a claim from an insured individual. This often includes reviewing, investigating, and deciding on whether the claim will be accepted or denied depending on the results of the insurer's investigation. This is a common procedure for all kinds of insurance including medical, auto, and liability insurance.

Here's how claim auditors use process claims:
  • Collect and process claims and follow up of billed amounts and reporting activities.
  • Train new hires to process claims for the cancer line of business.

9. Procedure Codes

Procedure codes are usually referred to as the medical classification that is used to identify surgical, medical, or diagnostic interventions like durable medical equipment, surgeries, medications. These codes can be structured alphanumerically, alphabetically, or numerically depending on where they are being used.

Here's how claim auditors use procedure codes:
  • Audit claims for billing, making sure all diagnosis, procedure codes, insurance information, and charges are entered correctly.
  • Use of Lotus Notes to submit additional pricing edits to the Professional Reimbursement Department for unlisted procedure codes.

10. Audit Results

Here's how claim auditors use audit results:
  • Communicate audit results to personnel, their management and regional management along with root cause analysis.
  • Present findings and make recommendations to appropriate management for improvement based on audit results.

11. ICD-9

Here's how claim auditors use icd-9:
  • Validated assigned ICD-9, CPT-4/HCPCS codes were coded in relation to service codes and revenue codes.
  • Research fee schedules, ICD-9 and CPT codes to insure claims are being paid correctly.

12. Provider Contracts

The definition of a provider contract is 'an agreement between a contracting entity and a provider according to which the provider agrees to deliver medical services to a claimant under this title in exchange for payment or reimbursement of an agreed-upon amount.' A provider contract relates to exactly one business partner. It consists of a contract header and contract items and details like contract start date, contract end date, authorization group, company code for authorization checks and the number of the business partner who entered the provider contract.

Here's how claim auditors use provider contracts:
  • Review provider contracts and/or pricing sheet attached by examiner.
  • Research Provider Contracts for payment accuracy

13. Data Entry

Data entry means entering data into a company's system with the help of a keyboard. A person responsible for entering data may also be asked to verify the authenticity of the data being entered. A person doing data entry must pay great attention to tiny details.

Here's how claim auditors use data entry:
  • Conducted data entry into company data systems.
  • Recorded and verified names, addresses, purchases and reactions of prospective customers, entered data entry of orders into computer.

14. Audit Claims

Here's how claim auditors use audit claims:
  • Audit claims for coordination of benefits, determine dental coverage per group contract and industry guidelines, process adjustments and correspondence.
  • Profiled and reviewed contracts to obtain correct benefit information to audit claims sorted and filtered from Connolly's Decipher System.

15. Appeals

Here's how claim auditors use appeals:
  • Conducted claims appeals and reviews for approval or denial decision in accordance within policy provisions and Medicare Guidelines.
  • Submitted appeals insurance follow-ups electronically, no fault, and workers compensation insurance.
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List of claim auditor skills to add to your resume

Claim auditor skills

The most important skills for a claim auditor resume and required skills for a claim auditor to have include:

  • Medical Terminology
  • Medicaid
  • Patients
  • HCPCS
  • CMS
  • Audit Findings
  • Medical Claims
  • Process Claims
  • Procedure Codes
  • Audit Results
  • ICD-9
  • Provider Contracts
  • Data Entry
  • Audit Claims
  • Appeals
  • Health Plan
  • ICD-10
  • Medical Billing
  • HMO
  • DRG
  • Quality Standards
  • Fee Schedules
  • Audit Reports
  • COB
  • Processing Guidelines
  • Medi-Cal
  • Health Insurance Claims
  • Claims Data
  • HIPAA
  • CPT-4
  • Claims Handling
  • TPA
  • Claims Examiners
  • Identify Trends
  • Analyze Data
  • Audit Process
  • Payment Accuracy
  • HCFA
  • Recovery Audit
  • Dental Claims
  • EOB
  • Hospital Claims
  • Hippa
  • Payment Errors
  • Insurance Carriers
  • Medical Necessity
  • Claims Issues
  • Facets
  • Provider Disputes
  • Medical Documentation

Updated January 8, 2025

Zippia Research Team
Zippia Team

Editorial Staff

The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

Updated January 8, 2025

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