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Claims Review Specialist
2 months ago
North American Staffing Group is excited to offer a remarkable opportunity for a dedicated Claims Auditor within a prominent healthcare organization. We are seeking an individual with a strong background in claims management, particularly those with at least 3 years of relevant experience. This role is ideal for candidates who demonstrate high motivation and possess excellent organizational skills. The organization offers 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.
- This role involves identifying overpayments and collaborating with the Claims Recovery Unit.
- Conduct audits of claims in accordance with applicable Federal and State regulations for the member's Line of Business.
- Analyze DOFRs to evaluate financial risks associated with group payments.
- Examine provider contracts to ensure accuracy in payments.
- Apply knowledge of Medi-Cal and Medicare Fee Schedules effectively.
- Utilize auditing tools to confirm the accuracy of claims payments.
- Engage 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 issues.
- Provide constructive feedback to the Claims Management team regarding process improvements and training requirements.
- Collaborate with the Recovery Department on identified overpayments.
- Foster positive working relationships with colleagues, clients, providers, and customers.
- Perform additional duties as assigned.
- High School Diploma or GED is required.
- A minimum of 3 years of experience in Claims Processing is essential.
- Familiarity with Medi-Cal regulations is necessary.
- Knowledge of Medicare and Commercial regulations is preferred.
- Understanding of medical terminology is required.
- Ability to interpret DOFRs and Contracts is essential.
- Familiarity with Managed Care concepts is beneficial.
- Strong organizational and mathematical skills are a must.
