Senior Claims Auditor

Job description: Company: Covet Health Location: New York, NY (Preferred) / Hybrid Reports to: Claims Supervisor

Covet Health is a modern, API-first TPA and benefits provider. We leverage technology and data-driven care pathways to improve healthcare delivery for employers and members. We prioritize transparency and precision in claims administration. We are seeking individuals who value operational excellence and innovation to join our growing team.

This role requires a minimum of 4 years of working at a healthcare payer as a claims processor/examiner with TPA knowledge.

What Will You Be Doing The essential functions listed represent the major duties of this role, additional duties may be assigned.

• Day-to-day processing of claims based on CPT, ICD-10, POS codes, provider types, etc. (Professional, Institutional, Mental Health, Vision and Dental)
• Claims processing and adjudication.
• Claims research where applicable such as reviewing Itemized bills, Medical Records, Authorization and members enrollment.
• Reviews and processes insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic).
• Utilize systems to track complaints and resolutions.
• As needed, other responsibilities include resolving complex benefit inquiries, conducting thorough root-cause research on plan benefits, verifying correct plan loading and system logic against Summary Plan Descriptions (SPDs), and actively interacting with claims managers, adjusters, and third-party administrators responsible for varying books of business. Additionally, this involves identifying system configuration discrepancies, maintaining benefit code update tracking, and collaborating with cross-functional teams such as finance and compliance to ensure optimal claims processing and plan integrity. Monitors and tracks daily output, leveraging available resources to maintain high accuracy and minimize errors.
• Manages daily and weekly assignments and assigned projects, adhering to detailed instructions to resolve high-priority claims and key issues.
• Remains up to date with daily communications with Manager and team, participating actively in daily huddles, team channels, and status syncs to ensure alignment on operational priorities and process updates.
• Meticulous attention to detail and strong analytical skills are essential for evaluating each claim to determine root cause. Candidates must understand cost-sharing principles and possess the ability to read UB-04 and CMS-1500 (HCFA) claim forms to distinguish between in-network and out-of-network coverage.

Qualifications

• Required: 4+ years related work experience in TPA claims examiner/adjudication experience on a computerized claims payment system in the healthcare industry.
• Required: Knowledge of CPT, HCPCS, RVU, and ICD-10 coding required.
• Required: Enhanced written and verbal communication skills required, including the ability to handle conflict.
• Required: Knowledge of COBRA, HIPAA, and coordination of benefits required.
• Required: Must possess proven judgment, decision-making skills and the ability to analyze.
• Must learn quickly as well as be able to multi-task.
• Must be motivated and possess a sound work ethic.
• Proficiency in maintaining good rapport with physicians, healthcare facilities, clients and providers.
• Experience and demonstrated proficiency in processing all types of medical claims.
• Experience in managing claims appeals and correspondence is a plus.
• Prior experience or knowledge in VBASoftware Database is Preferred but not required.

Covet Health is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

U.S. Citizen, U.S. Person, or Immigration Status Requirements: This job requires a U.S. Person. A U.S. Person is a lawful permanent resident as defined in 8 U.S.C. 1101(a)(20) or who is a protected individual as defined by 8 U.S.C. 1324b(a)(3). U.S. citizens, U.S. nationals, U.S. permanent residents, or individuals granted refugee or asylee status in the U.S. are considered U.S. persons. For a complete definition of “U.S. Person” go here. ecfr.gov/current/…/section-120.62

Job Type: Full-time Schedule: Monday to Friday Work Location: HYBRID - 3 days in Office (Midtown Manhattan) Job Type: Full-time Pay Expectations: Pay: $28 - $33 an hour.