Marketplace Claims Process Auditor

Location: St. Louis, MO
Marketplace Claims Process Auditor
Joining this team means you'll be surrounded by colleagues who are dedicated to meeting their own high standards, to inspiring their teammates and to making a positive impact on under-insured and uninsured individuals. The group is a fast, agile, customer-focused organization with a commitment to implementing the latest technologies.
Our client serves more than 55 million managed care members through their portfolio of high-quality commercial and government sponsored healthcare programs. The broad offering of programs that they provide has helped them to build both capacity and capability to successfully navigate a changing healthcare environment, while continuing to offer better health outcomes at lower costs.
Position Purpose:
Independently perform comprehensive audits of claims to source documents and identify incorrect payments.
Job Description:
  • Design and conduct audit planning and wrap up of engagements.
  • Utilize appropriate sources of information, including eligibility, enrollment and provider/facility contracts to conduct quality audits of claims, pre and post payments.
  • Execute review of Cost Sharing Reductions (CSR) reconciliation logic to ensure CSRs are applied correctly.
  • Confirm the accuracy of the accumulator process for deductible and out-of-pocket maximum.
  • Analyze errors and determine root causes for appropriate classification and facilitate corrective action plans.
  • Perform control total checks on the claims submitted to reconciliation tools.
  • Understand and support the resolution of errors.
  • Utilize audit software to provide written documentation regarding audit observations.
  • Monitor federal and state regulations and contract changes for impact on claim payments and update audit criteria as necessary
  • Summarize and communicate quarterly audit and related findings, recommendations, process improvement opportunities and best practices and assist in the consolidation and presentation of metrics, as needed.
  • Compare reconciliation reports against actuarial estimates on the member level. 
  • Coordinate and oversee testing of benefits to ensure benefit plan designs are applied correctly.
  • Validate benefit package, components, and the final plan design.
  • Assist with special projects  
  • Bachelor’s degree in Accounting, Finance, Business or related field or equivalent experience.
  • 3+ years of public accounting, internal audit or related operational or business experience. IT, Marketplace, auditing or health care industry experience required.
  • Knowledge of CPT/HCPCS Coding
  • 2+ years of medical or pharmacy claims processing, training or auditing experience.
  • Knowledge of claim software systems, Microsoft Office applications, Marketplace, Medicaid and/or Medicare reimbursement rules and the ability to interpret state and provider contracts preferred.
  • Knowledge of CPT/HCPCS Coding preferred.
License/Certification: CPA, CIA and/or CISA preferred
Our client offers options that allow you to do more than just plan for retirement. Their programs allow shared success with employees.
  • 401(k) with company match
  • Employee stock purchase plan
  • Training and Learning Opportunities/Tuition Reimbursement/Educational Assistance
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
Equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
April A. Estes
Senior Recruiter
720-439-2609 Direct
this job portal is powered by CATS