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Healthcare Claims Quality Auditor
2 months ago
Position Summary:
A Healthcare Claims Quality Auditor plays a crucial role in ensuring the integrity of claims processing and adherence to regulatory standards, in alignment with the contractual commitments of Health Plans and Hospital Clients. This position involves investigating, reviewing, and liaising with provider services regarding claims discrepancies and challenges as necessary. The auditor is expected to propose enhancements to processes and serve as a knowledgeable resource for all team members. Additionally, the Claims Auditor undertakes special projects and provides support to department leadership as required. They also evaluate and audit the claims adjudicated by Examiners for precision and offer constructive feedback.
Key Responsibilities:
- Conduct audits on claims processed daily through random sampling as per established organizational Policies and Procedures. Leverage relevant system-generated reports specific to specialty claims.
- Facilitate training sessions for Claims Examiners as needed. Prepare and maintain training documentation and participant records.
- Perform comprehensive investigations into contract-related issues, system challenges, and claims processing Policies and Procedures to identify root causes of trends. Propose solutions to Senior Management.
- Collaborate with various departments within the organization.
- Contribute to the formulation of Claims Department Policies and Procedures.
- Provide support for fellow auditors and trainers within the department.
- Execute additional tasks as assigned by Senior Management.
- Encourage a culture of teamwork and understanding among all staff members.
- Participate in organizational meetings as required.
- Comply with organizational Policies and Procedures.
- Embrace MedPOINT Management's core values: Accountability, Community, Celebration, Integrity, Innovation & Collaboration.
Minimum Qualifications:
- High School Diploma is mandatory.
- A minimum of three years of experience in a managed care claims adjudication environment, such as HMO/MSO, is required.
- In-depth knowledge of coding structures, including ICD-10, CPT-4, and Revenue Codes, is essential.
- A solid understanding of provider and health plan contracts, risk delineation, medical terminology, and standard industry reimbursement practices is necessary.
Required Knowledge, Skills, and Abilities:
- Exceptional organizational, analytical, and verbal/written communication skills in English are required.
- Proficiency in PC applications, including word processing and spreadsheets, is preferred.
- Experience in developing training materials and delivering presentations is advantageous.
- Ability to follow instructions and work independently while adhering to departmental standards is essential.
