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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.
- 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
- 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.