Claims Review Specialist
2 weeks ago
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.
- 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.
- 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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Claims Review Specialist
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