Claims Review Specialist

2 weeks ago


Montebello, California, United States North American Staffing Group Full time
Job Overview

North American Staffing Group is excited to offer a fantastic opportunity for a talented Claims Auditor to become part of a reputable healthcare organization. This role is essential for ensuring the accuracy and integrity of claims processing within the organization. The ideal candidate will have a minimum of 3 years of experience in claims management, coupled with strong organizational skills and a proactive approach to their work.

Key Responsibilities
  • The Claims Auditor will be responsible for meticulously reviewing and auditing claims that have been processed by the system and Claims Examiners.
  • They will provide insights and suggestions for process improvements to management, acting as a crucial resource for the entire team.
  • Identifying overpayments and working closely with the Claims Recovery Unit will be a significant part of this role.
Essential Duties
  • Conduct audits of claims to ensure compliance with applicable Federal and State regulations relevant to the member's Line of Business.
  • Analyze DOFRs to evaluate financial risks associated with group payments.
  • Examine provider contracts to confirm payment accuracy.
  • Apply knowledge of Medi-Cal and Medicare Fee Schedules in daily tasks.
  • Utilize auditing tools to ensure the precision of claims payments.
  • Collaborate with internal departments regarding provider issues, fee schedules, eligibility, and authorization.
  • Maintain documentation for tracking and trend analysis to identify and resolve system discrepancies.
  • Provide constructive feedback to the Claims Management team regarding process improvements and training requirements.
  • Work with the Recovery Department on any identified overpayments.
  • Foster positive working relationships with colleagues, clients, providers, and customers.
  • Perform additional duties as required.
Qualifications
  • High School Diploma or GED is required.
  • A minimum of 3 years of experience in Claims Processing is essential.
  • In-depth knowledge of Medi-Cal regulations is necessary.
  • Familiarity with Medicare and Commercial regulations is preferred.
  • Understanding of medical terminology is important.
  • Ability to interpret DOFRs and Contracts effectively.
  • Knowledge of Managed Care concepts is beneficial.
  • Strong organizational and mathematical skills are required.


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