Claims Quality Auditor

Description of services :

Audit a portion, as mutually agreed between the parties, of the combined financially stratified / attribute claim sample of medical and dental claims processed by medical care administrators. During the identified audit period (i.e., audits performed in 2024 will review claims processed through January 1, 2023 - through December 31, 2023, etc.). The audits will be conducted virtually with each administrator.

Tasks, Activities and Deliverables

The claims audit elements include review and validation :

The claimant was eligible for benefits on the date(s) of service based on data in the administrator's eligibility files,

• The provider's network participation was correctly determined based on the date of service,
• Claims requiring utilization review approval were reviewed and processed in accordance with utilization review decisions,
• Deductibles, coinsurance and other appropriate cost-sharing features of the benefit plan were considered and correctly applied,
• The claim data was entered into the claim system correctly, and whether a paper claim was keyed or scanned,
• Appropriate checks were made to ensure that there was no other coverage available to the claimant or, if there was other coverage, payments were coordinated correctly,
• The "reasonable and customary" or provider discount features of the plan were correctly applied, including unbundling for physician services,
• Appropriate edits were made to ensure that the claim was not paid twice,
• The procedure(s) billed and paid were, in fact, covered by the plan and do not appear to be fraudulent billings by the provider,
• The mathematics and computations were correct,
• Any pre-authorization limits were appropriately applied,
• The paper claim form was completed appropriately and signed by the appropriate parties,
• The administrator adhered to its own internal policies and procedures when processing the claim,
• Appropriate approvals were applied to high dollar claims (pre- and post-payment), and
• Sufficient documentation was included in the file to support the adjudication of the claim.

Education and Experience

Skills

Personal Attributes