[Hiring] Claims Auditor II @Horizon Blue Cross Blue Shield of New Jersey

Role Description

Performs 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, in accordance with established audit criteria and program-specific guidance.
• Complete assigned audit volumes within established production expectations while maintaining required accuracy, quality, and documentation standards.
• Identify processing errors, variances, or noncompliant outcomes during sample review; cite findings as audit points; and document rationale and supporting evidence clearly, accurately, and independently.
• Manage assigned audit points through follow-up and resolution activities, including communication, validation, documentation updates, and closure within established timeframes.
• Partner with business areas and internal team members to obtain clarification, confirm root cause information, support audit point resolution, and ensure findings are addressed appropriately.
• Use applicable systems and tools to complete audit work and document results, including NASCO, Blue Squared, Local, BlueCard, other supporting operational systems, and the department’s audit tool.
• Maintain complete, accurate, and organized audit documentation to support findings, audit point activity, re-review, reporting, and audit readiness.
• Support consistency across the audit function by participating in calibration activities, sharing knowledge, and assisting with onboarding or guidance for less experienced auditors as appropriate.
• Escalate unclear, conflicting, or complex scenarios to senior auditors or management, as appropriate, while demonstrating sound judgment and increasing independence in audit execution.
• Perform other job-related duties, special assignments, and operational support activities, as assigned by management, to meet departmental, regulatory, and business needs.

Qualifications

• High School Diploma/GED required.
• 3-5 years of claims processing experience required.

Requirements

• Systems knowledge (e.g. NASCO).

Benefits

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