Claims Audit Specialist

At WelbeHealth, we serve our communities’ most vulnerable seniors through shared intention, pioneering spirit, and the courage to love. These core values and our participant-focus lead the way no matter what.

The Claims Audit Specialist is accountable for ensuring the timely and accurate payment or denial of claims while meeting federal/state regulations, provider agreement terms, and company policies and procedures. This role requires a strong knowledge of health plan operations, including the proper processing of professional, institutional, and dental claims, coding, CMS/Medi-Cal regulations, and in-depth comprehension of provider contracts and agreements. The Claims Audit Specialist collaborates effectively with Plan Operations leadership to identify trends that require escalation and training needs, and suggest process improvements.

This role is different because the Claims Audit Specialist at WelbeHealth:

• Ensures accuracy and compliance by auditing complex Medicare and Medi-Cal claims, directly impacting financial integrity, regulatory adherence, and provider trust
• Plays a key role in identifying trends, mitigating risk, and driving process improvements across claims operations, helping strengthen overall system performance and reduce errors

We care about our team members. That’s why we offer:

• Medical insurance coverage (Medical, Dental, Vision)
• Work/life balance - We mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days
• 401K savings + match
• Comprehensive compensation package including base pay and bonus
• And additional benefits!

On the day-to-day, you will:

• Review processed claims for pre and post payment accuracy while maintaining acceptable levels of aged claims inventory
• Ensure claim payment accuracy by verifying various aspects of the claim form, including but not limited to participant eligibility, system configuration, payment accuracy or denial appropriateness, provider records, remark codes, pre-authorization requirements, timely filing limitations, claim history, and W9 receipt
• Maintain detailed documentation of audit findings, including decision methodology, system configuration or manual processing errors, and monetary discrepancies
• Regularly provide feedback to the Oversight & Monitoring Manager on claims processing errors, as well as identify quality improvement opportunities and initiate configuration change requests when applicable
• Accurately process and release high dollar/stop loss claims exceeding $10k
• Participate in annual claims audits to cure any deficiencies in claims system, human error, or possible fraud, waste, and abuse in order to maintain contractual and regulatory compliance
• Act as a back up to the Claims team as needed

Job requirements include:

• Bachelor’s degree in relevant field; professional experience may be substituted
• Minimum of five (5) years of experience processing, researching, adjusting, and auditing Medicare and Medicaid professional, institutional, and dental health insurance claims
• Experience processing and auditing disputes, appeals and recoveries
• Proficient experience in Microsoft Excel
• Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, ICD-10 codes, and relevant federal and state regulations
• Experience working with CMS and Medi-Cal healthcare claims
• Strong organizational, analytical, communication, and time management skills

We are seeking a Claims Audit Specialist who is passionate about accuracy, compliance, and continuous improvement within healthcare operations. If you are driven to make a meaningful impact by ensuring claims integrity and supporting high-quality, compliant processes, we’d love to hear from you!