Aggregate Claims Auditor

**This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for an Aggregate Claims Auditor based in United States.** This role offers an opportunity to support accurate and efficient claims management within a specialized insurance environment. As an Aggregate Claims Auditor, you will review complex health plan claims, evaluate contract compliance, and determine appropriate liability and reimbursement decisions. You will play a key role in protecting financial accuracy by auditing claims approaching aggregate attachment points and maintaining accurate reserves. Working remotely, you will collaborate with clients and third-party administrators to resolve discrepancies and ensure adherence to policy requirements. The position combines analytical expertise, healthcare knowledge, and attention to detail to deliver high-quality claims outcomes. This is an ideal opportunity for professionals who enjoy investigative work, problem-solving, and contributing to reliable insurance operations. ### Accountabilities - Investigate claims liability and determine the appropriate level of responsibility for submitted claims under aggregate insurance contracts. - Review and interpret employer health plans, excess insurance policies, and contract documentation to ensure accurate claims processing. - Audit monthly and year-end aggregate claims from initial review through final completion, following established quality and turnaround standards. - Analyze claims reports, eligibility records, funding documentation, check registers, prescription reports, and related data to verify compliance with plan requirements. - Communicate with third-party administrators (TPAs) and clients to resolve claim processing issues, obtain missing documentation, and clarify discrepancies. - Establish, maintain, and adjust claims reserves based on current liability assessments and contract obligations. - Determine appropriate reimbursement amounts, including identification of non-covered or out-of-contract expenses. - Coordinate recovery efforts and obtain refunds when overpayments or excessive monthly accommodations are identified. - Review operational processes of TPAs and clients to ensure alignment with contractual guidelines and internal standards. - Maintain high standards of accuracy, confidentiality, productivity, and customer service throughout the claims auditing process. ## Requirements - Bachelor’s degree in Business Administration, a related field, or equivalent combination of education and professional experience. - Minimum of 2 years of relevant and progressive experience in claims auditing, insurance operations, healthcare claims, or a related field. - Broad understanding of claims auditing principles, practices, procedures, and insurance operations. - Strong medical knowledge, including ICD-10 codes, CPT codes, medical terminology, COBRA, and HIPAA requirements. - Ability to interpret complex documents, including benefit plans, claims reports, contracts, and procedural manuals. - Strong analytical and organizational skills with the ability to manage multiple priorities and meet deadlines. - Excellent written and verbal communication skills with a focus on professionalism, confidentiality, tact, and diplomacy. - Detail-oriented mindset with strong problem-solving abilities and the ability to identify discrepancies and recommend appropriate actions. ## Benefits - Competitive salary range of **$50,500 to $111,500**, depending on geographic location, qualifications, experience, education, and skill level. - Fully remote work opportunity within the United States. - Comprehensive medical, dental, and vision insurance coverage beginning on the first day of employment. - Basic life insurance and disability coverage. - 401(k) retirement plan with a 6% company match. - 20 days of paid time off, floating holidays, paid holidays, and volunteer time off. - Paid parental leave. - Access to wellness pr…