Medical Claims Auditor

Other Park Ridge, Illinois


Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Job Summary:

The Medical Claims Auditor is responsible for auditing and monitoring trends and performing special analyses. Medical Claims Auditor individual will take the lead to ensure accurate and timely adjudication of claims, as well as identifying potential issues, and recommending strategies for resolution. The individual is responsible for reviewing and analyzing complex projects and reports results directly to management. Apply claim and/or inquiry processing experience to audit and analyze simple to advanced-level claims processing procedures and workflows.

This is a full time 40 hour a week opportunity. The company offers a competitive benefits package, along with paid time off, tuition reimbursement and 401(k).  A competitive salary is offered.

Main Accountabilities:

  • Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows to ensure proper guidelines are met per CMS and company standards.
  • Apply claim researching experience to audit and analyze all levels of research to ensure proper guidelines are met per CMS and company standards.
  • Apply claim configuration experience to audit and analyze all levels of configuration to ensure proper guidelines are met per CMS and company standards. Take charge of testing and communicating with the internal/external configuration dept and present updates for claims processing enhancements.
  • Assigned to handle second-level review for claims prior to the release of payment. Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.
  • Handle complex and urgent special projects from external providers and internal departments.
  • Assist the Claims Research department with high-profile projects. Must have the ability to accurately make the necessary adjustments for underpayments and review overpayment requests for Claims Recovery.
  • Support Sr Claims Processors when training Jr Claims Processors on analyzing Claim error trends and coach if need.
  • Analyze and prepare Health plan claims selections for Annual health plan audits. Review samples provided by clerical staff and ensure claim payments are accurate and all documentation required by the health plan auditor are present at the time of audit.
  • Assist the Claims Research in corresponding with external providers regarding Claims Overpayment requests. Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.
  • Other duties and responsibilities as may be assigned by Upper Management if need. 


  • Minimum of five years’ experience in healthcare claims processing, audits or appeals, or an equivalent combination of education, training and experience with a health plan, health system or insurance carrier
  • Computer proficiency in a Windows environment, knowledge of Microsoft Office products
  • Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
  • Strong knowledge of medical terminology
  • Knowledge of CPT Codes, HCPCs and ICD-10 codes
  • Medicaid and Medicare experience required
  • Candidate must be detail oriented with strong organization and prioritization skills
  • Strong commitment to customer service and quality required
  • Proven decision-making skills and ability to multi-task required
  • Willingness to coach junior staff and lead special projects as needed
  • Effective analytical, problem solving and mathematical skills
  • BA/BS degree preferred, or equivalent experience required
  • Available to work a shift that starts at 8am or later