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Claims Auditor I

4 weeks ago

Redding, California, United States Partnership HealthPlan of California Full time
Job Summary

As a Claims Auditor I at Partnership HealthPlan of California, you will be responsible for performing concurrent, retrospective, and special audits on all level I claim types for all PHC lines of business. This role requires a strong understanding of PHC Claims Policy and Procedures, as well as knowledge of Medi-Cal Provider Manual, Title 22 regulations, Knox Keene regulations, and CMS Medicare regulations.

Key Responsibilities
  • Conduct audits on new claims examining staff and claims processed by existing Claims staff as outlined in Claims Operating Instruction Memorandums for all lines of business.
  • Document audits and report all audit outcomes following the PHC Claims Operating Instruction Memorandums on claims auditing.
  • Maintain current knowledge of PHC Claims Policy and Procedures for all lines of business, Medi-Cal Provider Manual, Title 22 regulations, Knox Keene regulations, and CMS Medicare regulations.
  • Perform special claims audits as assigned.
Secondary Duties and Responsibilities
  • Participate in special projects and assignments as required.
  • Other duties as assigned.
Qualifications

Minimum two (2) years of claims examining experience and completion of PHC Claims training; or equivalent combination of education and experience. Familiar with Medi-Cal and/or managed care claims processing. Knowledge of CPT, HCPC procedure coding, and ICD-9/ICD-10 diagnostic coding. Typing speed 30 wpm and proficient use of 10-key calculator. Familiar with AMISYS or similar claims systems. Understanding of claims examining requirements. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes conflicting priorities. Good organizational skills with ability to maintain accurate records and documentation of actions and decisions.

Work Environment and Physical Demands

Ability to use a computer keyboard. More than 60% of work time is spent in front of a computer monitor. When required, ability to move, carry or lift objects of varying size, weighing up to 5 lbs.

Company Culture

All HealthPlan employees are expected to: provide the highest possible level of service to clients; promote teamwork and cooperative effort among employees; maintain safe practices; and abide by the HealthPlan's policies and procedures, as they may from time to time be updated.

Hiring Range: $36.46