Healthcare Claims Auditor

SUMMARY:

The Medical Claims Auditor will be responsible for checking the claim for completeness, for compliance with procedures and to ensure that the costs are in line with the service or diagnosis received by utilizing online reference, Plan Summary Descriptions, Provider Contracts, and/or current coding manuals. Medical Claims Auditor must be experienced and extremely detail-oriented, precise and thorough. Knowledge of facility and ancillary claims processing experience is required. Knowledge of medical terminology is a must, as is a broad understanding of health insurance administration processes and standard guidelines. Knowledge of CPT, HCPCS, and ICD-9 Coding is essential.

POSITION DUTIES & RESPONSIBILITIES:

• Audit completed claims for all products / Ensure daily self-audit report are performed by the claims team.
• Perform all daily self-audit reports.
• Audits randomly selected claims to ensure quality processing.
• Follows adjudication policies and procedures to ensure proper payment of claims.
• Follows the eligibility research protocol including verifying member benefits and COB.
• Review authorization status codes and notes affecting the adjudication of the claim.
• Submit claims inquiry to UM per protocol.
• Perform audits of claims involving high dollar and network specialty pools.
• Apply provider contract rates appropriately based on effective dates and amendment updates.
• Meet productivity and error ratio standard as required.
• Reconcile Health Plan error reports as required.
• Adjudicate processional, facility, and high dollar claims in accordance with Managed Care Operations, CMS, and AZPC Guidelines.
• Researches reports from various data sources for management.
• Analyzes audit results for trends and root cause issues.
• Maintains/track production and quality scores for each employee.
• Creates and maintains auditing policies and procedures.
• Conduct periodic post audit of claims to alleviate any incorrect decisions.
• Communication with management on audit findings, assist with error validation process.
• Utilizes the plan documents in order to properly adjudicate claims and answer questions regarding claims. Fee schedules and Medicare regulations are provided for determining proper payment.
• Research and resolve, working with Claim team, customer service issues in a timely manner to ensure quality claims service.
• Assist claims management in training of team regarding contract application and disseminating info regarding adjudication policies and procedures.
• All other duties as assigned.

EDUCATION, TRAINING AND EXPERIENCE:

• High school diploma or equivalent (GED)
• Minimum 5 years recent claims experience.
• Claims auditing experience desired.
• Knowledge of medicine and medical terminology, CPT, HCPCS, ICD-9, and DSM codes.
• Must have experience with UB92 forms.
• Strong knowledge of Medicare Billing & Payment guidelines as well as CMS CCI Edits.
• Familiar with all regulatory requirements including CMS and DHS.
• Must be able to work under general guidance of Claims Lead with little direct supervision.
• Must be meticulous and pay attention to detail.
• EzCap experience is a plus.
• Strong data entry skills (10,000 key strokes alpha/numerical).
• Must be able to work independently and exercise judgment.
• Must be able to work on computer systems, accessing multiple files.

*This is a hybrid position, effective after first 90 days of mandatory in-office training*