Claims Auditor
4 weeks ago
The medical claims auditor will be responsible for checking the claim for completeness, for compliance with procedures and to ensure that the costs are in line with the service or diagnosis received by utilizing online reference, Plan Summary Descriptions, Provider Contracts, and/or current coding manuals. Medical Claims Auditor must be experienced and extremely detail-oriented, precise and thorough. Knowledge of facility and ancillary claims processing experience is required. Knowledge of medical terminology is a must, as is a broad understanding of health insurance administration processes and standard guidelines. Knowledge of CPT, HCPCS, and ICD-9 Coding is essential.
- Audit completed claims for all products / Ensure daily self-audit report are performed by the claims team.
- Perform all daily self-audit reports.
- Audits randomly selected claims to ensure quality processing.
- Follows adjudication policies and procedures to ensure proper payment of claims.
- Follows the eligibility research protocol including verifying member benefits and COB.
- Review authorization status codes and notes affecting the adjudication of the claim.
- Submit claims inquiry to UM per protocol.
- Perform audits of claims involving high dollar and network specialty pools.
- Meet productivity and error ratio standard as required.
- Reconcile Health Plan error reports as required.
- Adjudicate professional, facility and high dollar claims in accordance with Managed Care Operations, CMS and AZPC Guidelines.
- Researches reports from various data sources for management.
- Analyzes audit results for trends and root cause issues.
- Maintains/track production and quality scores for each employee.
- Creates and maintains auditing policies and procedures.
- Conduct periodic post audit of claims to alleviate any incorrect decisions
- Communication with management on audit findings, assist with error validation process
- Utilizes the plan documents in order to properly adjudicate claims and answer questions regarding claims. Fee schedules and Medicare regulations are provided for determining proper payment.
- Research and resolve, working with Claim team, customer service issues in a timely manner to ensure quality claims service.
- Perform other duties as assigned.
(11152)
- High school diploma or equivalent required.
- Minimum 5 years recent claims and/or billing experience.
- Claims auditing experience desired.
- Knowledge of medicine and medical terminology, CPT, HCPCS, ICD.9, and DSM codes
- Must have experience with UB92 forms
- Familiar with all regulatory requirements including CMS and DHS
- Must be able to work under general guidance of Claims Lead with little direct supervision
- Must be meticulous and pay attention to detail.
- EZ-Cap experience is a plus
- Strong data entry skills (10,000 keys strokes alpha/numerical)
- Must be able to work independently and exercise judgment
- Must be able to work on computer systems, accessing multiple files
- At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.
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