Claims Auditor II

Horizon Connect @ Wall BCBSNJ

. Perform audit samples on benefit coding, reimbursement, pricing, PIBA and pharmacy to ensure accurate claim adjudication and reimbursement.

Posted 11/9/2026full-timeRemote • United StatesMid-LevelSenior💰 $63,000 - $84,420 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in audit processes, claims processing, and compliance standards, with a strong focus on accuracy and documentation. Proficient in utilizing operational systems and tools to identify errors and manage audit findings effectively.

Highest-signal resume keywords

Claims Processing ExperienceAudit Documentation ManagementError Identification and ResolutionKnowledge of NASCOCollaboration with Business Areas

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Audit Sample ReviewClaim AdjudicationReimbursement AnalysisVariance IdentificationDocumentation Standards

Soft Skills

Attention to DetailProblem-SolvingCommunicationTeam CollaborationKnowledge Sharing

Tools & Technologies

NASCOBlue SquaredBlueCardOperational SystemsAudit Tool

Industry Keywords

Benefit CodingReimbursementEDIAudit ProgramsCompliance

About the role

Key responsibilities & impact

Perform audit samples on benefit coding, reimbursement, pricing, PIBA and pharmacy to ensure accurate claim adjudication and reimbursement.
Independently review assigned audit samples across PG, LOS, LDLA, and FEP audit programs, including claims, EDI, portal, inquiries, membership, and other operational work types.
Complete assigned audit volumes while maintaining accuracy, quality, and documentation standards.
Identify processing errors, variances, or noncompliant outcomes; cite audit points; and document rationale and supporting evidence.
Manage audit points through follow-up, validation, documentation updates, and closure.
Partner with business areas and internal team members to clarify information, confirm root causes, and resolve findings.
Use NASCO, Blue Squared, Local, BlueCard, supporting operational systems, and the department’s audit tool.
Maintain organized audit documentation for findings, re-review, reporting, and audit readiness.
Participate in calibration activities, share knowledge, and assist with onboarding or guidance for less experienced auditors.
Escalate unclear, conflicting, or complex scenarios to senior auditors or management.
Perform other job-related duties, special assignments, and operational support activities as assigned.

Requirements

What you’ll need

High School Diploma/GED required.
3-5 years of claims processing experience required.
Knowledge of systems such as NASCO.
Employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware.

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement