Virginia Premier Health Plan, Inc.

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Claims Prepayment Auditor

Claims Prepayment Auditor

Job Locations 
US-VA-Glen Allen
Job ID 

Job Description


The Claims Prepayment Auditor is responsible for the internal auditing of claim accuracy of claims processed according to the benefit structure to ensure accurate adjudication of healthcare claims payment.  The Claims Prepayment Auditor must be thoroughly familiar with claims processing/adjudication processes, fee schedules, contract terms, standard operating procedures, and DMAS/DHHS regulations. The Claims Prepayment Auditor is also responsible for communicating with internal and external customers on the outcome of the integrity of medical payments for the organization through verification of the accuracy of data-entered information.  It is expected that the Claims Prepayment Auditor is able to research issues, problem resolve and make appropriate decisions as it relates to claims processing. The Claims Prepayment Auditor must also be capable of developing a working relationship with regulatory agencies.  The level of involvement depends on the specific line of business. The Claims Prepayment Auditor may provide education and feedback to staff involved in the related processes.


In addition, the Claims Prepayment Auditor is responsible for all aspects of High Dollar quality assurance within the Claims job family. Conducts High Dollar audits and provides feedback to reduce errors and improve processes and performance.


  • Establish claims auditing program, to include, payment accuracy, SOP processing guidelines, fee schedule, and contract review.
  • Conduct quality assurance audits for all lines of business in the claims adjudication process.
  • Establish turnaround times to respond to individual audit errors.
  • Provide In-services to staff members on new and existing regulatory guidelines (DMAS/DHHS).
  • Participate in appropriate and approved training classes during year (in accordance with goals).
  • Prepare and present monthly, quarterly, departmental, and individual results to the appropriate management staff.
  • Develop audit form to communicate feedback to frontline staff.
  • Must possess a high level of technical expertise in the claims application system, fee schedules, and contract configuration.
  • Work high dollar claims weekly to uncover over payments.
  • Ability to audit claims according to benefit structure, fee schedule and medical payment policies.
  • Report any inconsistencies that are identified in regards to internal department policies and procedures to the management.
  • Work with the management staff to ensure all existing workloads have been addressed and are within acceptable time frames.
  • Provide management with required documentation to assist with performance Scorecard feedback.
  • Identify trends and process improvements; and be apart of implementing changes to improve overall quality.
  • Uses professional concepts and company policies and procedures to solve a wide range of difficult problems in a realistic and practical way.
  • Exercises judgment within defined procedures and practices to determine appropriate action.
  • Met expected performance goals outlined for a Pre-Payment Auditor



  • High school diploma
  • Certification in medical terminology from an acceptable entity preferred.


  • Strong verbal and written communication skills
  • Strong organizational skills
  • Exposure to health care environment and in-depth knowledge of CMS 1500 and UB04 claim forms
  • CPT-4, ICD9 and HCPCS knowledge
  • Ability to work independently
  • Ability to meet deadlines and work under pressure


  • Requires a minimum four (4) years claims processing and/or healthcare billing experience with 2 to 3 years of claims auditing experience
  • Intermediate competency in MS Applications (Excel, Access, Power Point).
  • Should meet or exceed performance metrics for 6 consecutive months (internal).
  • Must demonstrate proficiency in current role for one year (internal). 


  • Physical health sufficient to meet the ergonomic standards and demands of the position.



Virginia Premier Health Plan, Inc. is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 


We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  


All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE


Our mission is to inspire healthy living within the communities we serve!




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