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Senior Claims Auditor

3 months ago

Miami, United States Leon Health Full time


The Sr Claims Auditor ensures incoming claims are processed in accordance with policies, procedures and guidelines, as outlined by Leon Health and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts.

The Claims Auditor will be responsible for pre-payment, post-payment validations and the management of operational reporting, testing and data submissions.

Summary of Essential Duties and Responsibilities

  • Apply Medicare Claim Payment rules and requirements, including the application of National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements to claims received for payment.
  • Enter claim data accurately and timely, in alignment with departmental production and quality goals
  • Ensure claims payments are made within time frames as reflected in contractual agreements
  • Maintain a minimum of 98% accuracy at all times
  • Perform pre-payment audits and post payment audits to validate claims for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding) and validate accurate claim adjudication rules and fee schedules were applied
  • Perform pre-payment high dollar claim audits
  • Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with Leon Health contractual guidelines
  • Manage difficult, non-routine or escalated claims by using comprehensive research and thorough knowledge of Medicare payment rules
  • Identify and manage third party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers or members. Perform outreach and recovery efforts to Third Party Administrators.
  • Coordinate with Finance department for claim payments, voids and refunds. Apply adjustments to the claim payment system as necessary.
  • Refer claims for medical management claim review as necessary/applicable.
  • Outreach to providers for additional information, including medical records to validate Medicare criteria is met prior to approving a claim for payment.
  • Educate providers on billing requirements to reduce claim submission rejections and denials. Educate providers on prior authorization requirements.
  • Review and process provider payment disputes according to Leon Health policies and contractual requirements.
  • Review and process member requests for reimbursement of claims.
  • Create and distribute claim inventory and aging reports as needed. Create ad hoc claim data extracts as needed.
  • Create and validate claim reports (Organizational Determinations) prior to submission to CMS to ensure accuracy and completeness of data files
  • Assist in the effectuation of overturned appeals made by Leon Health or federal contractor/entity
  • Assist in the research and resolution of payment disputes and appeals
  • Assist in the creation of case files for the QIO, IRE or other state or federal entity upon request
  • Identify and refer potential fraud and abuse cases to the Compliance Department
  • Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs
  • Identify opportunities for claims adjudication process improvements
  • Perform User Acceptance Testing and support implementation of tools and systems for the Claims Department
  • Assist in the training of new staff on claims processing policies, procedures and systems
  • Filing and light administrative duties associated with claims processing
  • Other duties and responsibilities as may be assigned.
Minimum Requirements

  • High School diploma or GED equivalent; Associates degree in a related field is preferred
  • Minimum of five years' experience in healthcare claims processing, or an equivalent combination of education, training and experience
  • Medicaid and Medicare claim processing experience preferred
  • Strong understanding of claims processing workflow and payment rules
  • Computer proficiency in a Windows environment, knowledge of Microsoft Office products with an emphasis in Excel.
  • Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
  • Strong knowledge of medical terminology, CPT Codes, HCPCs codes and ICD-10
  • Knowledge of CMS pricers and vendor pricing software
  • Strong written skills to accurately complete required documentation within the time frames specified
Abilities Required

  • Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
  • Ability to read, write and communicate at a professional level
  • Effective time management and organizational skills
  • Effective interpersonal and communication skills