[Hiring] Claims Auditor REMOTE USA

Position: Claims Auditor

Date Posted: December 28, 2025

Industry: Healthcare / Insurance / Claims Management

Employment Type: Full Time

Experience: 1–3 years as medical/dental claims auditor

Qualification: BS/BA degree preferred or equivalent experience in healthcare claims auditing

Salary: $46,669.19 – $65,668.60/yr

Location: United States REMOTE

Company: Pinnacle Claims Management / Western Growers Health

Description:
We’re Hiring – Claims Auditor

Pinnacle Claims Management, part of the Western Growers Health family, is seeking a dedicated Claims Auditor to join our remote team in the United States. This role involves performing in-depth audits to ensure medical and dental claims of our clients comply with their respective summary plan descriptions, supporting the overall integrity and efficiency of our claims processing.

Key Responsibilities:

Claims Auditing:

• Conduct routine and moderately complex audits on paper and electronic claims to ensure payment integrity in line with regulations, policies, and contract terms.
• Verify proper coding and system configuration of claims; extract and audit exception reports.
• Research claim processing errors and determine appropriate resolutions.
• Prepare detailed audit reports and summarize observations and recommendations for management.
• Collaborate with management on trends to improve claims accuracy and integrate findings into training programs, policies, and procedures.
• Execute special project audits as requested.

Claims Department Support:

• Identify gaps or inaccuracies in instructional materials and recommend corrections.
• Assess and support departmental training needs related to policy, procedural, or regulatory changes.
• Analyze error logs and contribute findings to training preparations.
• Provide technical support and expertise to claims staff and other departments.
• Assist management in updating departmental policies and guidelines.

Pinnacle Risk Management Services – Claims – PM6000:

• Adjudicate stop loss claims from Third Party Administrators according to policy terms.
• Process complex claims for physicians, hospitals, and specialty areas with high accuracy.
• Manage claim adjustments, refunds, and payments per company policies.
• Coordinate claims status with reinsurance carriers and support AVP of Claims, Claims Manager, and Reinsurance Analyst as needed.
• Identify process improvement opportunities and implement corrective actions.

Other Duties:

• Collaborate and plan work to enhance competitiveness and profitability for members.
• Exhibit curiosity, accountability, and a helpful attitude while delivering results.
• Perform other duties as assigned to support team and organizational goals.

Qualifications:

• BS/BA degree preferred.
• 1–3 years recent experience as a medical/dental claims auditor.
• Experience processing group health claims preferred.
• Knowledge of CPT, ICD-10/ICD-9, medical terminology, and provider contracts.
• Strong written and verbal communication skills.
• Proficiency with word processing and spreadsheet software.
• Ability to interpret summary plan descriptions and manage timelines effectively.
• Strong analytical and business math skills.

Physical Demands/Work Environment:

• Ability to communicate effectively and move around the office as needed.
• Use of tools, objects, and controls in a moderate noise environment.
• Reasonable accommodations provided for individuals with disabilities.

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