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Claims Auditor
SureCompanies
 
Job Location: Santa Ana, CA
Description:

SureCo is a PURPOSE driven company that's dedicated to disrupting our broken healthcare system. We're 100% focused on driving down the cost of healthcare and improving the quality of care for all of us. SureCo and its subsidiaries and partners are at the forefront of health care change in the U.S. Serving patients, consumers, and enterprises. We focus on innovative technologies, new care paradigms, all focused on aligning our incentives with our customers. Established in 2016 we've grown from 10 to over 100 (and counting) Sureconians what we call our awesome team members!


If you are looking for a company focused on making real change, high energy, and team-driven performance then you've found it here at SureCo. Our people are inspiring and are inspired by what we do, who we get to do it with, and who we do it for.


Summary


The Claims Auditor is responsible for working with the Senior Claims Manager to ensure compliance with applicable rules and regulations set forth. Responsible for maintaining routine auditing functions and providing feedback on departmental activities to ensure ongoing compliance with claim inventory.


Key Responsibilities


  • Evaluates claims adjudication using standard principles and state-specific policies and regulations in order to ensure accurate and timely claims adjudication
  • Performs moderately sophisticated claim audits on a routine basis for payment accuracy by following regulatory standards, and business policies
  • Conducts quality assurance audits for claim adjustments, refunds, and provider disputes
  • Performs focused reviews and provides reports to the Compliance team
  • Tracks and monitors all audit scores in a database
  • Assists in preparing audit reports as requested
  • Verifying and adjudicating provider claims in moderate to high-level complexity categories.
  • Adjudicate all professional (HCFA) and/or institutional (UB) and outpatient facility claims. Responsible for meeting or exceeding production and quality standards for all specific types of claim
  • Route claims that cannot be finalized.
  • Research, resolve and respond to inquiries and problems of a moderately complex nature.
  • Follow claims policies and procedures.
  • Interface with other departments, when necessary, regarding claims issues.
  • Assist the Senior Claim Manager when asked to research and audit claims for health plan compliance.
  • Participate in Claims Department staff meetings and other activities as needed.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in health plans policies and procedures relating to HIPAA compliance.
  • Responsible for mentoring newer analysts/examiners.
  • Perform other duties as assigned including claims auditing and data analysis

PM20

.Requirements:
  • 3 5 years of experience in examining and processing all medical claim types; professional and institutional. Medicare/Medi-Cal experience required.
  • Experience with claim adjustments, provider appeals, and/or disputes
  • Intermediate knowledge of medical terminology.
  • Communication and analytical skills. Strong computer and data entry skills. Advanced 10 key 70 strokes per minute. Typing 50 WPM.
  • Knowledge of CPT, ICD, and HCPCS codes.




PI131838563





 
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