Claims Audit Analyst

Who we are.

At Blue Cross Blue Shield Global Solutions℠ (BCBS Global Solutions℠), we make it easy for people and organizations to access and pay for healthcare abroad. By combining digital innovation with human-centered care, we go above and beyond for our customers and deliver an international healthcare experience that's simple, efficient, and human.

Whether our customers live, work, travel, or study abroad, we give them the confidence and peace of mind to say "yes" to new possibilities.

What we're looking for in our Claims Audit Analyst:

You're someone who enjoys evaluating complex claims, ensuring quality and accuracy, and identifying opportunities to improve processes. You have a strong analytical mindset and take pride in maintaining high standards while supporting operational excellence. You thrive in an environment where attention to detail, critical thinking, and data-driven decision-making are essential.

You're someone who:

• Has exceptional attention to detail and a passion for quality assurance
• Enjoys identifying trends, errors, and process improvement opportunities
• Maintains objectivity and consistency when reviewing work completed by others
• Uses sound judgment when making decisions and documenting findings
• Communicates audit results clearly and professionally
• Balances accuracy, compliance, and productivity in a fast-paced environment
• Is comfortable analyzing data and presenting meaningful insights to leadership Collaborates effectively across departments to support operational excellence

Here's the work you'll be doing to support claims quality and audit operations:

Claims Quality Auditing

• Conduct quality audits of claims that exceed processor payment authority levels
• Perform routine and random audits of claim processing activities to ensure compliance with company policies, client requirements, and regulatory guidelines
• Review claims adjudication decisions for accuracy, consistency, and adherence to benefit provisions
• Evaluate work completed by Claims Analysts, Claims Adjusters, Payment Specialists, and other operational team members
• Maintain audit schedules and ensure required audit volumes are completed within established timeframes Support client-specific auditing requirements for Classic, BCBS Global Core, FEP, and other business lines as assigned

Audit Reporting & Trend Analysis

• Compile audit findings and maintain accurate audit documentation
• Prepare monthly audit statistics and quality performance reports for leadership
• Analyze audit results to identify trends, recurring issues, training opportunities, and operational risks
• Provide actionable recommendations to improve quality, consistency, and efficiency Support internal and external audit initiatives, including Association and client audits

Compliance & Operational Support

• Review surcharge reports, approval queues, and other quality control processes as assigned
• Complete high-dollar claim notifications, stop-loss filings, and related documentation
• Respond to audit-related inquiries and requests from internal stakeholders
• Ensure claims processing activities align with client requirements, company standards, and applicable regulations Partner with operational teams to clarify findings and support corrective action planning

Quality Improvement & Collaboration

• Assist with departmental quality initiatives and continuous improvement efforts
• Share audit insights and best practices that help improve overall claims accuracy
• Collaborate with leadership to support training and performance development programs
• Promote a culture of quality, accountability, and operational excellence Support additional projects and responsibilities as assigned

This might be the right fit for you if...

• You have a high school diploma or equivalent; additional education or certifications are a plus
• You have 5+ years of experience in health insurance claims examination, adjudication, or related healthcare operations roles
• You have strong knowledge of medical claims processing, benefit structures, and insurance terminology
• You understand CPT, ICD-10, and healthcare reimbursement concepts
• You are highly analytical with strong problem-solving and decision-making abilities
• You have excellent written and verbal communication skills
• You are comfortable interpreting policies, identifying exceptions, and documenting audit findings
• You are proficient with Microsoft Office and comfortable working within claims administration systems You can effectively manage multiple priorities while maintaining accuracy and objectivity

Bonus points if you have:

• Experience performing claims quality audits
• CPC, CCS, or other coding certifications
• Experience supporting Federal Employee Program (FEP) audits
• Knowledge of BCBS Association audit requirements
• Experience creating audit reports, scorecards, or trend analyses
• Experience presenting findings and recommendations to leadership Experience working in a highly regulated healthcare environment

What you'll get in return:

• Competitive base pay + annual bonus
• Competitive medical plans
• Telemedicine services
• Paid parental leave
• 24/7 employee assistance and wellness support Free international healthcare coverage

Other great perks:

• Hybrid work model (office and/or remote)
• Work-abroad arrangements available
• Generous PTO accrual with carry-over options
• 9 paid holidays, plus one floating holiday and one volunteer day
• Tuition reimbursement
• Career development and learning opportunities
• 401(k) with generous company match
• Pet insurance options
• Identity theft and legal coverage Ongoing focus on well-being, including virtual wellness resources and mindfulness events

Please visit the employee benefits page on our website for more information on our benefits and perks that support your overall well-being.

EOE