Claims Quality Auditor
3 weeks ago
As a Claims Quality Auditor at MetroPlusHealth, you will play a vital role in ensuring the accuracy and integrity of our claims processing system. Your expertise in claims coding, contracting, and reimbursement methodologies will be essential in identifying trends and irregularities, and recommending corrective actions to improve the claims adjudication process.
Key Responsibilities
- Audit daily processed claims to determine if payments have been made correctly.
- Document, track, and trend findings to identify areas for improvement.
- Develop and implement training programs to educate Claims Examiners on best practices and industry regulations.
- Collaborate with other departments to develop corrective action plans to improve accuracy and compliance.
- Assist in the development of Claims policies and procedures.
- Provide backup for other trainers within the department.
- Assist with the research and resolution of audit appeals.
- Participate in quality projects as required.
Requirements
- Associate degree required; Bachelor's degree preferred.
- Minimum of 4 years of experience performing claims quality audits in a managed care setting.
- Expertise in professional and institutional claims coding, and coding rules required.
- Strong knowledge of CMS Medicare and NYS regulations required.
- Excellent interpersonal, verbal, and written communication skills.
Professional Competencies
- Strong organizational, analytical, and oral/written communication skills required.
- Proficiency in PC application skills, e.g., Excel, Word, PowerPoint, etc.
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