What does a claim auditor do?
A claims auditor is primarily in charge of processing and auditing claims in companies and other institutions, ensuring accuracy and smooth workflow. Their responsibilities include coordinating with staff to gather the necessary data, liaising with clients to identify their needs, assessing the eligibility and validity of claims, verifying payments, and maintaining records of all transactions. Furthermore, as a claims auditor, it is essential to ensure that all claims and payments are carried out in adherence to the company's policies and regulations.
Claim auditor responsibilities
Here are examples of responsibilities from real claim auditor resumes:
- Work with department analyst to create measurement tools and methods for communicating results and managing QA analysis in compiling/reporting results.
- Bill and prepare claims appeals for Medicare, Medicaid, and private payers.
- Review medical records and charges of hospital, ambulatory surgery and physician bills to verify CPT, ICD-9 and HCPCS codes.
- Research and determine accuracy of ICD-9 and CPT codes on CMS 1500 and UB 92 claims forms on a daily basis.
- Evaluate DRG grouping and pricing information.
- Audit all claims types for a Medicare HMO plan.
- Perform analysis using proficient CPT, HCPCS and ICD9-CM knowledge.
- Calculate the amount of overpayment given per contract, coding and cob.
- Audit all claims in accordance with performance standards, HIPAA specifications and corporate rules.
- Travele to various customer sights as a representative of MetLife for medical benefit meetings.
- Position require attention to detail as well as knowledge of HIPAA laws and Medicare guidelines.
- Review all require systems and databases within MetLife to obtain all necessary information to pay claims
- Review patient records to maintain that HCC documentation guidelines designate by CMS are followed by providers.
- Validate assigned ICD-9, CPT-4/HCPCS codes are coded in relation to service codes and revenue codes.
- Ensure that claims are processed according to company procedures, HMO and PPO plans, and Medicare guidelines.
Claim auditor skills and personality traits
We calculated that 9% of Claim Auditors are proficient in Medical Terminology, Medicaid, and Patients. They’re also known for soft skills such as Organizational skills, Analytical skills, and Detail oriented.
We break down the percentage of Claim Auditors that have these skills listed on their resume here:
- Medical Terminology, 9%
Required extensive knowledge of medical terminology and coding.
- Medicaid, 8%
Researched Medicaid State reimbursement regulations for claim payment compliance reviews and documentation to support audit findings.
- Patients, 6%
Contacted self care patients to set up payment plans for services rendered as wee as working AR reports past 90 days.
- HCPCS, 5%
Analyze medical records for consistency and completeness using ICD-9, CPT-4 and HCPCS Level II established criteria and regulations.
- CMS, 5%
Reviewed patient records to maintain that HCC documentation guidelines designated by CMS were followed by providers.
- Audit Findings, 5%
Analyzed and validated audit findings according to payer regulations and payer processing guidelines / provider contracts.
Most claim auditors use their skills in "medical terminology," "medicaid," and "patients" to do their jobs. You can find more detail on essential claim auditor responsibilities here:
Organizational skills. To carry out their duties, the most important skill for a claim auditor to have is organizational skills. Their role and responsibilities require that "strong organizational skills are important for accountants and auditors, who often work with a range of financial documents for a variety of clients." Claim auditors often use organizational skills in their day-to-day job, as shown by this real resume: "demonstrated customer service and organizational skills in a fast-paced environment. "
Detail oriented. claim auditors are also known for detail oriented, which are critical to their duties. You can see how this skill relates to claim auditor responsibilities, because "accountants and auditors must pay attention to detail when compiling and examining documents." A claim auditor resume example shows how detail oriented is used in the workplace: "prepared detail reports of audit findings, control deficiencies and summary for review by the school audit committee. "
Communication skills. claim auditor responsibilities often require "communication skills." The duties that rely on this skill are shown by the fact that "accountants and auditors must be able to listen to and discuss facts and concerns from clients, managers, and other stakeholders." This resume example shows what claim auditors do with communication skills on a typical day: "developed improved communication standards with patients, claims adjusters, outpatient services and physicians. "
Math skills. A commonly-found skill in claim auditor job descriptions, "math skills" is essential to what claim auditors do. Claim auditor responsibilities rely on this skill because "accountants and auditors must be able to analyze, compare, and interpret facts and figures." You can also see how claim auditor duties rely on math skills in this resume example: "analyze and process claims thorough knowledge of procedures and practices, equipment, medical terminology and business math. "
The three companies that hire the most claim auditors are:
- Centene13 claim auditors jobs
- Cook Children's Medical Center4 claim auditors jobs
- Crawford & Company3 claim auditors jobs
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Compare different claim auditors
Claim auditor vs. Audit specialist
An audit specialist is responsible for evaluating the reports by a professional auditor that will assist in improving the growth of the organization to achieve its goals and objectives. Audit specialists aid in the development of the company by using a systematic approach to reach the goals set by the company. Primary responsibilities include operating complex and difficult audit projects and conducting audits of control, financial, and other operating records. Also, they develop, implement distinct audit strategies, programs, and procedures for intricate assignments.
There are some key differences in the responsibilities of each position. For example, claim auditor responsibilities require skills like "medical terminology," "hcpcs," "process claims," and "procedure codes." Meanwhile a typical audit specialist has skills in areas such as "customer service," "internal audit," "corrective action," and "internal controls." This difference in skills reveals the differences in what each career does.
Audit specialists earn the highest salaries when working in the professional industry, with an average yearly salary of $72,330. On the other hand, claim auditors are paid more in the insurance industry with an average salary of $50,913.On average, audit specialists reach similar levels of education than claim auditors. Audit specialists are 2.0% more likely to earn a Master's Degree and 0.1% less likely to graduate with a Doctoral Degree.Claim auditor vs. Medical claims processor
A medical claims processor has working knowledge of medical billing and coding. The qualifications for this position include knowledge of current procedural terminology (CPT) and international classification of diseases (ICD) coding systems. They are responsible for processing claims forms, adjudicating the allocation of deductibles and copays, and following through with adjudication policies to facilitate proper payment of claims.
In addition to the difference in salary, there are some other key differences worth noting. For example, claim auditor responsibilities are more likely to require skills like "audit findings," "medical claims," "audit results," and "audit claims." Meanwhile, a medical claims processor has duties that require skills in areas such as "healthcare," "medical insurance claims," "customer service," and "medical charts." These differences highlight just how different the day-to-day in each role looks.
Medical claims processors may earn a lower salary than claim auditors, but medical claims processors earn the most pay in the government industry with an average salary of $42,406. On the other hand, claim auditors receive higher pay in the insurance industry, where they earn an average salary of $50,913.medical claims processors earn similar levels of education than claim auditors in general. They're 4.5% less likely to graduate with a Master's Degree and 0.1% less likely to earn a Doctoral Degree.Claim auditor vs. Auditor supervisor
An auditor supervisor is a financial professional who manages a staff of audit professionals and controls consulting engagements that evaluate the management and operating practices of a corporate. This supervisor is required to supervise audit planning and fieldwork as well as communicates findings and recommendations to senior management. To ensure that audit staff follows the department's methodology, the supervisor must supervise the audit staff and review their automated audit work papers. The supervisor must also ensure that reviews are following the standards of the corporate audit department and the Institute of Internal Auditors (IIA).
There are many key differences between these two careers, including some of the skills required to perform responsibilities within each role. For example, a claim auditor is likely to be skilled in "medical terminology," "medicaid," "patients," and "hcpcs," while a typical auditor supervisor is skilled in "cpa," "excellent interpersonal," "internal audit," and "business processes."
Auditor supervisors earn the best pay in the finance industry, where they command an average salary of $86,925. Claim auditors earn the highest pay from the insurance industry, with an average salary of $50,913.auditor supervisors typically earn similar educational levels compared to claim auditors. Specifically, they're 2.8% more likely to graduate with a Master's Degree, and 0.6% more likely to earn a Doctoral Degree.Claim auditor vs. Auditor/quality
A quality auditor is responsible for inspecting the company's services and products, ensuring its adherence to business requirements and internal regulations. Quality auditors analyze the efficiency of operational functions and production processes to maintain high-quality deliverables with the utmost consideration for the safety and security of the production staff. They run quality checks for the outputs, create findings reports, and strategize methodologies to enhance stability by utilizing standard testing parameters. A quality auditor must have excellent communication and organizational skills, as they may also recommend opportunities to generate more resources and increase revenues.
Types of claim auditor
Updated January 8, 2025
