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Claims Examination Specialist
2 months ago
North American Staffing Group is excited to offer a direct-hire position for a proficient Claims Auditor. Our client, a well-regarded healthcare organization, is seeking an individual with a strong background in claims management. Candidates should have at least 3 years of relevant experience, a proactive attitude, and outstanding organizational skills. This role comes with a competitive salary and a comprehensive benefits package.
Key Responsibilities- The Claims Auditor will be responsible for meticulously reviewing and auditing claims processed by the system and Claims Examiners.
- They will provide recommendations for process improvements to management and serve as a key resource for all staff members.
- The Claims Auditor will identify overpayments and work closely with the Claims Recovery Unit.
- Conduct audits of claims in accordance 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 ensure accuracy in payments.
- Understand and apply Medi-Cal and Medicare Fee Schedules effectively.
- Utilize auditing tools to confirm the accuracy of claims payments.
- Collaborate with internal departments regarding provider, fee schedule, eligibility, authorization, or system-related issues.
- Document data for tracking and trend analysis to identify and resolve system challenges.
- Provide constructive feedback to the Claims Management team regarding process improvements and training requirements.
- Engage with the Recovery Department concerning identified overpayments.
- Foster positive working relationships with colleagues, clients, providers, and customers.
- Perform additional duties as assigned.
- High School Diploma or GED.
- Minimum of 3 years of experience in Claims Processing.
- In-depth knowledge of Medi-Cal regulations.
- Familiarity with Medicare and Commercial regulations is preferred.
- Understanding of medical terminology.
- Ability to interpret DOFRs and Contracts.
- Knowledge of Managed Care concepts.
- Strong organizational and mathematical abilities.
