Claims Auditor Career

Functional Skills are essential skills that help individuals perform tasks effectively in everyday life, work, and education.

Claims Analysis and Evaluation

Medical Coding and Terminology

Insurance Policy Interpretation

Fraud Detection and Investigation

Data Analysis and Reporting

Regulatory Compliance

Negotiation and Communication

Documentation and Record Keeping

Problem-Solving and Critical Thinking

Customer Service

Communication, teamwork, and critical thinking to ensure seamless project execution.

Technical Skills are specialized abilities and knowledge needed to perform specific tasks or functions.

Task

95%

Verify the accuracy and completeness of claim information, ensuring all necessary documentation is present.

90%

Evaluate medical claims for adherence to policy benefits, medical necessity, and appropriate coding guidelines.

85%

Identify and investigate potentially fraudulent claims, working with special investigation units as needed.

80%

Communicate with healthcare providers and policyholders to obtain additional information or clarify claim details.

75%

Apply knowledge of medical terminology, CPT, ICD, and HCPCS coding systems to accurately process claims.

70%

Document claim reviews and actions taken in the claims processing system, maintaining detailed records.

65%

Stay updated on changes in healthcare regulations, coding guidelines, and insurance policies.

60%

Participate in training sessions and quality assurance reviews to improve claims auditing skills.

Work Activities

Detailed Work Profile

Interests