Clinical Claims Auditor

in New York City
, NY
Reference: 19-04223


The Clinical Claims Auditor examines claims and service authorizations to determine and correct any inaccuracies, prevent claim errors, and increase provider satisfaction.


  • Examine provider claims and service authorizations for completeness and accuracy
  • Review different large sets of claims data to recommend changes in the claims submission and authorization processes
  • Communicate to Care Management teams any inaccuracies found along with recommended solutions
  • Communicate with providers regarding any claim or authorization issues
  • Review CPT procedure codes for verification of medical necessity
  • Follow up with providers to ensure outstanding issues are resolved and to increase and promote overall provider satisfaction level
  • Compile recurring issues and deficiencies to be used in the re-education of the team to prevent errors
  • Complete documentation in Patient Health Information database (CCMS)
  • Document any provider complaints and/or incidents upon notification
  • Notify manager of any provider issues and concerns
  • RightFax referrals and authorization approvals and denials upon providers request