Claims Auditor

Community Health Group is seeking a skilled Claims Auditor to promote and maintain the quality and accuracy rate of claims paid by our organization. The successful candidate will conduct pre-disbursement audits for fee for service claims, compile and track audit results, and recommend training and improvement ideas.

Key Responsibilities:

• Conduct pre-disbursement audits of targeted claims, providers, or processes to identify processing errors, inappropriate billing, and possible fraud.
• Analyze data to identify trends and recommend improvements to staff training and provider education.
• Act as a backup to the VE Claims Auditors and perform related functions.
• Provide recommendations for staff training and provider education based on audit findings.
• Assess information from various sources and generate trend reports.
• Audit claims with payment amounts over $5,000 for Professional claims and $10,000 for Hospital claims.
• Identify errors, billing inconsistencies, and system configuration issues and report them to the Claims Audits Supervisor.
• Complete tort liability reporting and compile Third Party Liability claims information.

Requirements:

• AA degree and coding and/or medical terminology certificate.
• Minimum of five years of experience analyzing and processing claims.
• Strong knowledge of Medi-Cal and Medicare payment guidelines.
• Solid healthcare and managed care background.
• Vast knowledge in claims coding and auditing.
• Clear understanding of medical record review.
• Ability to handle confidential information with professionalism.
• Proficiency in Microsoft Office.
• Excellent verbal, written, organizational, and analytical skills.

About Community Health Group:

Community Health Group is a locally-based nonprofit health plan serving over 360,000 members in San Diego County. We are dedicated to coordinating quality care and providing exceptional customer service. Our employees are committed to protecting the most vulnerable people in our society by providing access to culturally sensitive, quality care.