Claims Auditor

Summary

Auditor is responsible for the overall quality of claims processes as well as compliance, in accordance with outside regulations and the contractual obligations of the Health Plans and/or the IPAs. Researches, reviews and contacts provider services for problem claims and issues, as needed. Suggests process improvements to management and is a resource of information to all staff. The Claims auditor also performs special projects and helps department manager and director as needed.

Duties and Responsibilities

• Audit daily processed claims through random selection as outlined by organizational Policies and Procedures. Utilize appropriate system-generated reports applicable to specialty claims.
• Document, track and trend findings per organizational guidelines for Senior Management.
• Based upon trends, determine ongoing Claims Examiner training needs and develop/implement training programs as approved by Senior Management.
• Conduct Claims Examiner training as required. Document training materials and attendees. Conduct feedback process to assure training needs have been met, e.g. post-training testing.
• Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions to Senior Management.
• Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations.
• Assist in the development of Claims Department Policies and Procedures.
• Provide backup for other auditors/trainers within the Department.
• Assist in training of new departmental staff.
• Perform other tasks as assigned by Senior Management.
• Promote a spirit of cooperation and understanding among all personnel.
• Attend organizational meetings as required
• Adhere to organizational Policies and Procedures.

Minimum Job Requirements

High School Diploma required. Three years of experience in a managed care claims adjudication setting e.g., HMO/MSO, required. Expertise in coding structure, ICD-9, ICD-10, CPT-4 and Revenue Codes, required. Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.

Knowledge, Skills and Abilities Required

• Strong organizational, analytical and oral/ written communication (English) skills required.
• Previous computer experience required.
• Proficiency in PC application skills, e.g., word processing, spreadsheets, preferred.
• Strong knowledge of HCFA and state regulations required.
• Experience in training development and presentation preferred
• Claims audit experience preferred.
• Must be able to follow direction and perform independently according to departmental standards when no direction is given.