General Purpose/Scope:
The Claims Auditor is responsible for the auditing functions of the Companys claims. The incumbent will collaborate with other health plan departments and Delegated Vendors to ensure claims are processed in accordance with Federal, State and Integras established guidelines and/or policies and procedures. The incumbent will also participate in compliance reviews of delegated vendors claims processing policies and procedures. Additionally, the Claims Auditor will provide feedback or recommendations to enhance current processes and/or systems.
Responsibilities Include:
Claim Auditing
Conducts weekly audits of Integras claims utilizing Company guidelines, policies and procedures or any other regulatory requirements. Reviews internal and Delegated Vendor production reports to ensure compliance with all regulatory requirements and Integras policies. Identifies and documents claim issues resulting from audits or other internal resources. Participates in on site audits of the Delegated Vendors as required. Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements. Maintains documentation of changes to claim processing guidelines and where appropriate, ensures policies and procedures are created or updated. Communicates and follows up either orally or in writing with a variety of internal and external sources including but not limited to providers, members, attorneys, regulatory agencies, and other carriers on any claim audit related matters. Evaluates Prospective Payment System (PPS) (e.g. APC, DRG, etc.) grouping and pricing information. Meets individual and departmental standards with regards to quality and productivity. Provides expertise and assistance relative to provider billing and payment guidelines consistent with the Companys policies and procedures and State or CMS guidelines. Performs other duties and special projects as assigned and directed.
Call monitoring
Conducts weekly call auditing using quality monitoring tools to compile and track performance at individual and team levels. Provides actionable data to management to help identify training needs and trends. Prepares and analyzes internal and external quality reports related to call performance. Develops, recommends, and monitors corrective and preventive actions
Qualifications:
BA/BS degree in a financial field or equivalent healthcare experience 3+ years of claim customer service and claim processing experience with a Medicaid/Medicare Health Plan
Skills/Abilities:
Strong telephonic and customer service skills Effective presentation skills Excellent verbal and written communication skills Must be able to participate in meetings with all levels of management within the organization Outstanding detail orientation, with excellent follow up skills Ability to multi-task in a fast-paced environment Must be service oriented, a self-starter and collaborative Proficiency with MS applications, including but not limited to Word, Excel, Outlook, Power Point, Microsoft Access or similar querying tool.

Covid-19 Vaccination Guidance: The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Anthem approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws.

Integra is an Equal Opportunity Employer and prohibits discrimination or harassment based on any characteristics protected by the laws or regulations in the locations where we operate.

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