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Health Claim Auditor

Goahead Solutions
Detroit, Michigan, United States
November 13, 2016

Healthcare Claims Auditor (Contractor)

I am seeking seeking healthcare claims auditors to support its Cost-Share Reduction (CSR) reconciliation services. CSR is mandated under the Affordable Care Act, and health plans providing individual and small group policies must annually reconcile the actual cost of reduced member cost sharing (i.e., deductible, copay, coinsurance, and out-of-pocket maximum) against advance payments received from CMS. To assist with the reconciliations, we are looking for individuals with the following skills and experience:


• Become proficient in the proprietary data analysis and audit tools

• Participate in internal and external project kick-off meetings to gain understanding of client’s needs

• Translate the client’s healthcare Summary Plan Descriptions into plan builds in our proprietary audit rules engine

• Analyze re-adjudicated claims output from audit tool to refine plan build and Cost-Share Reduction (CSR) reconciliation

• Assist team with preparing client deliverables and responding to client questions


• Deep understanding of healthcare claims processing gained through working for a health plan or TPA

• Working knowledge of how health plans or TPAs build benefit plans in their claims processing system

• Proficient with all healthcare coding methods (e.g., CPT, HCPCS, DRG, ICD-9, ICD-10, Revenue Codes).

• Strong analytical and problem solving skills.

• Detail oriented with ability to work on multiple client assignments simultaneously.

• Excellent computer skills (Microsoft Word, Excel, Outlook).