The Claims Auditor is responsible for reviewing claims processed by examiners based on provider and health plan contractual agreements and claims processing guidelines. Follows all internal processes and procedures to ensure claims audit activities are handled in accordance with departmental and company policies and procedures. Excellent knowledge of claims processing rules and Medicare regulatory requirements. Maintains production standards as established by departmental management to meet quality requirements, ensure payment integrity, identify root cause and training opportunities.
Responsibilities:
Reviews claims for statistical and payment accuracy. Ensure appropriate payments or denials, and use of adjustment or reason codes are correct
Identifies root cause of errors and work with internal departments for resolution
Review claims for fraud, waste or abuse and notifies management of such findings.
Updates systems, tracking tools or other documentation methods as needed.
Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement.
Prepares and issue audit reports which include audit findings, scores and corrective actions
Monitors completion of corrections
Assists with training of claims examiners based on identified errors
Submit monthly audit reports to Management.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).
Actively participates in ongoing training to support company and department initiatives.
Supports department initiatives in improving processes and workflow efficiencies
Adheres to all regulatory and company standards, as described in the Employee Handbook and departmental Policies and Procedures.
Complies with company's time and attendance policy.
Promotes teamwork and cooperation with other staff members and management
Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.
Performs additional related duties as assigned by Management
Required Sills and Experience:
3+ years medical claims auditing experience in HMO or IPA/Medical Group setting required, preferably Medicare claims
5+ years' experience in examining all types of medical claims, preferably Medicare claims
Bachelor's degree in healthcare management or related field, a plus
Other: Experience working with Provider Dispute and Appeals
Proficiency in Microsoft Office programs (Excel, Access, Word), intermediate level
Experience using claims processing systems (EZCAP preferred).
Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
Working knowledge of different claims payment methodologies and claim editing guidelines
Familiarity with CMS regulations related to Part C claims
Understanding of Division of Financial Responsibility on how they apply to claims processing
Knowledge of claims processing requirements which include but not limited to eligibility, HMO benefit structures and coordination of benefits
Proven problem-solving skills and ability to translate knowledge to the department.
