Purpose Statement / Position Summary The Claims Auditor performs research analytics to support payment and recovery efforts for multiple lines of business. The auditor will implement audit/review methodologies for a variety of healthcare claims to identify errors, trends, and system issues. The auditor will assist the audit supervisor and compliance manager to determine patterns and provide recommendations to prevent future mistakes.
Essential Functions and Responsibilities of the Job
Conducts pre and post payment claim audits on adjudicated medical claims to ensure claims are processed in accordance with hospital/provider contracts, member plan benefits, compliance, and company policies and procedures.
Conducts pre and post adjustment/PDR/reopening audits in accordance with compliance and company policies and procedures.
Conducts claim code edit audits and make necessary corrections according to V.E. recommendations, compliance, and company policies and procedures.
Compiles error data including underpayments/overpayments to generate periodic reports
Communicates errors to examiners daily
Works with supervisor and manager to identify error trends and provide recommendations to fix claims issues.
1-2 years experience in claims auditing preferred
Minimum of 1-3 years claims processing experience in an IPA, Medical Group or Health Plan
Computer literacy on PC based software programs, including Microsoft Excel & Word
Understands and interprets Health Plan Division of Financial Responsibility (DOFR)
Background in Managed Care industry
Comprehensive knowledge of ICD-9, CPT, and HCPCS codes, medical terminology, and COB
Comprehensive knowledge of various fee schedules – DRG, APC, ASC, RBRVS
Strong analytical, mathematical and problem solving skills
Demonstrates effective communication, interpersonal, and organizational skills