Claims Auditor

The Claims Auditor performs analysis and monitors trends identified through the audit process. This individual will take the lead to ensure accurate and timely adjudication of claims, as well as identifying potential issues and recommending strategies for resolution. Apply claim and/or inquiry processing experience to audit and analyze simple to advanced-level claims processing procedures and workflows.

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS. Job Responsibilities/Duties

• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows. Requires the ability to audit claims accurately. Independently run reports on errors identified for potential error trends and report the results to Claims Management and Claims Trainer. Additionally assist in the processing of PDRs , Health Plan Cap Deducts, and claims processing.
• Handle special projects from external provider and internal departments. Must have the ability to accurately make the necessary adjustments for underpayments and review overpayment requests for Claims Recovery Specialist.
• Independently audit and analyze high dollar claims and checks prior to the issuance of funds. Must possess the ability to analyze Claims EOB and balance check amounts according to Claims processing guidelines.
• Analyze and prepare Health plan claims selections for Annual health plan audit. Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor is present at the time of audit.
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests. Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.

Qualifications

Minimum Education: High School Diploma or Equivalent. BS/BA preferred.

Minimum Experience: Two to three (2-3) years previous experience as medical claims Auditor or 3-5 years previous experience examining medical Claims preferred. Preferably in an IPA, MSO, or Medical Group setting.

Req. Certification/Licensure: None

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