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Medical Claims Auditor

Verify that health insurance claims are accurately filled out.

What does a Medical Claims Auditor do?

After a patient sees their Doctor, they submit what’s known as a claim to their insurance company. This claim explains what procedure was done and how much it cost, and details if it is covered by the patient’s insurance. Medical Claims Auditors check up on claims to make sure they are filled out correctly and completely, and for the right amount.

As a Medical Claims Auditor, you act as a sort of Guard against insurance fraud. You contact patients, hospitals, and Doctors to make sure procedures were actually completed, and to check up on medical costs. When you’re a Medical Claims Auditor you might do this only on claims that seem suspicious, or on random claims to keep people honest.

Throughout your investigation of claims, you keep clear records of everything you do. If a lawsuit or investigation needs to happen on an incorrect claim, it’s necessary that there’s openness with regard to how you did your investigation. When you find an incorrect claim, you can do one of two things.

First, it might just be a mistake, a form that’s filled out incorrectly or missing vital information, so in this case, you simply contact the Doctor or patient for more information, and finish filling out the claim. Second, if you find an amount on a claim that is way higher than it should be, or if you find procedures that never happened, you turn the information over to a Supervisor. From here, they decide what actions to take, and these can be anything from claim adjustment to legal proceedings.