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Claim Auditor Jobs (NOW HIRING)

Cook Children's

Claim Auditor I

Fort Worth, TX · On-site

The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP ...

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DMC Insurance, Inc.

Claims Auditor

Indianapolis, IN · On-site

The Claim Auditor is responsible for auditing internal and external claim files for excess reporting compliance, reserving adequacy, quality assurance, adequate resolution plan. This is a position ...

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How much do claim auditor jobs pay per hour?

As of Sep 1, 2026, the average hourly pay for claim auditor in the United States is $26.83, according to ZipRecruiter salary data. Most workers in this role earn between $19.71 and $29.81 per hour, depending on experience, location, and employer.

What is a claim auditor?

Claim auditors are professionals who review and evaluate insurance claims to ensure their accuracy, legitimacy, and compliance with company policies and regulations. They analyze documentation, verify billing codes, and check for errors or fraud in submitted claims. The goal of a claim auditor is to minimize financial losses for insurers and ensure that policyholders and providers receive fair and proper payments. Claim auditors may work for insurance companies, third-party administrators, or healthcare organizations. Their work helps maintain the integrity of the claims process and supports efficient operations.

What are the key skills and qualifications needed to thrive as a claim auditor, and why are they important?

To thrive as a Claim Auditor, you need a strong understanding of insurance policies, claim processing procedures, and attention to detail, typically supported by a degree in business, finance, or a related field. Familiarity with claims management systems, auditing software, and sometimes certifications like Certified Professional Medical Auditor (CPMA) are commonly required. Analytical thinking, integrity, and effective communication are crucial soft skills for investigating claims and collaborating with stakeholders. These skills ensure accurate claim evaluation, fraud prevention, and compliance with regulatory standards.

What are some common challenges faced by claim auditors and how can they be addressed?

Claim Auditors often encounter challenges such as reviewing large volumes of complex claim files, interpreting varying policy guidelines, and ensuring compliance with both internal and external regulations. Staying organized and detail-oriented is crucial, as is keeping up-to-date with changes in policies or industry regulations. Effective communication with claims adjusters and other departments helps resolve discrepancies quickly and ensures accurate claim processing. Joining regular training sessions and leveraging audit software tools can also help streamline workflows and reduce errors.

What is the difference between Claim Auditor vs Claims Processor?

AspectClaim AuditorClaims Processor
Required CredentialsTypically requires a certification in claims auditing or insuranceOften requires basic insurance or claims processing training
Work EnvironmentOffice setting, reviewing claims for accuracy and complianceOffice or call center, entering and processing claims data
Employer & IndustryInsurance companies, third-party administratorsInsurance companies, healthcare providers

Claim Auditors focus on reviewing and verifying claims for accuracy and compliance, often requiring specialized certifications. Claims Processors handle the entry and initial processing of claims, typically with less emphasis on auditing skills. Both roles are essential in the insurance industry but differ in responsibilities and required credentials.

How to become a claim auditor?

To become a claim auditor, typically one needs a high school diploma or equivalent, with some roles preferring an associate's or bachelor's degree in fields like accounting, finance, or insurance. Relevant skills include attention to detail, knowledge of insurance policies, and proficiency with auditing tools or software. Certification such as the Certified Professional Insurance Auditor (CPIA) can enhance job prospects.
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Infographic showing various Claim Auditor job openings in the United States as of August 2026, with employment types broken down into 79% Full Time, 19% Part Time, and 2% Contract. Highlights an 84% Physical, 5% Hybrid, and 11% Remote job distribution, with an average salary of $55,805 per year, or $26.8 per hour.

Claim Auditor I

Cook Children's Health Care System

Fort Worth, TX

Full-time

Re-posted 8 days ago

Cook Children's Health Care System rating

7.9

Company rating: 7.9 out of 10

Based on 78 frontline employees who took The Breakroom Quiz

107th of 896 rated healthcare providers

Job description

Location:

Calmont Operations Building

Department:

Reimbursement Analysis

Shift:

First Shift (United States of America)

Standard Weekly Hours:

40

Summary:

The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle.

Additional Information:

  • The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle.


Education:

  • Associates degree required or a minimum of 5 years of claims/audit experience which includes experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment preferred. 7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding.
  • Must have strong organizational skills, problem solving and decision-making skills. Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs.
  • Microsoft Office skills including Word, Excel and Access. Excellent customer service skills with ability to explain complicated benefit issues to staff and providers.

Certification/Licensure:

About Us:

Cook Children's Health Plan

Cook Children's Health Plan provides vital coverage to nearly 120,000 people in low-income families who qualify for government-sponsored programs in our six county service region. Cook Children's Health Plan provides health coverage for CHIP, CHIP Perinatal, STAR (Medicaid) and STAR Kids Members in the Tarrant county service area. The counties we serve includes Tarrant, Johnson, Denton, Parker, Hood and Wise.

Cook Children's is an EOE/AA, Minority/Female/Disability/Veteran employer.

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About Cook Children's Health Care System

Sourced by ZipRecruiter

Cook Children's Health Care System, based in Fort Worth, Texas, operates in the healthcare industry with a primary focus on pediatric health services. Established in 1918, the system has been committed to improving the health of children through the prevention and treatment of childhood diseases. This integrated pediatric healthcare system includes a medical center, physician network, home health company, research institute, and a health plan. At the core of its operations is the mission to 'Improve the Health of Every Child' in its community, reflecting its commitment to providing quality care, research, education, and prevention and wellness services.

Industry

Health care and social assistance

Company size

5,001 - 10,000 Employees

Headquarters location

Fort Worth, TX, US

Year founded

1918

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