Non-Clinical - Finance/Accounting - Claims Processor

Claims Auditor

The Claims Auditor assists in the Claims Department by analyzing procedures, policies and reports; ensures appropriate payment of claims and maintenance of the claims system as necessary.

Specific Skills Needed:

• Knowledge of HMO/or IPA operations; medical terminology; ICD-10, RVS, and CPT coding knowledge; knowledge of Medicare and Medi-Cal guidelines; 10-key skills by touch; excellent communication skills; knowledge of system applications; ability to function effectively under time deadlines; strong organizational skills.

Required: Formal training will be indicated by a high school diploma or equivalent; four years medical claims processing.

Preferred:

• Department Management to list.

Duties and Responsibilities:

• Safeguards and preserves the confidentiality of patient's protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies.
• Ensures a safe patient environment and adherence to safety practices per policy.
• With consideration to age, employee utilizes the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care.
• Assist the Claims Director in the training and education of the Claims department staff.
• Coordinate the generation and review of claims audit, status and pending claims reports ensuring authorized claims are paid in accordance with company guidelines.
• Investigate, process and track payment adjustments including refunds, overpayments and underpayments.
• Act as a confidential and professional resource for group providers and other staff.
• Act as a resource for providers, members, insurance carriers, attorneys and co-workers, researching and responding to questions in a timely manner.
• Create, maintain and generate system reports.
• Interface with the Claims Director to ensure claims processing functions meet legal and contractual requirements with regards to health plan audits.
• Prepare and present weekly and monthly reports reflecting staff and departmental quality statistics.
• Review and audit member liability denials and Provider Dispute Resolution claims to ensure compliance with regulatory requirements and passing audit scores from health plans.
• Perform other duties as assigned.

Teamwork/Customer Service Responsibilities:

• Customer Service Values and Behaviors:
• Value: Each person is treated with respect, dignity, fairness and compassion. Behavior: Performance is acceptable when everyone is promptly greeted with a smile in a warm and caring manner using the person's name whenever possible. No matter how I feel, I display a caring attitude.
• Value: Each person displays loyalty and pride in PIH Health and upholds the confidentiality of patients, visitors, physicians, and co-workers. Behavior: Performance is acceptable when concerns/problems with fellow employees and customers are not discussed with anyone other than the person involved or the supervisor. Customer issues and ideas are listened to and appropriate follow up occurs to create a satisfied customer. I do not make excuses. I do not demean other people or departments.
• Value: Each person demonstrates commitment to open communication. Behavior: Performance is acceptable when openness and acceptance of constructive criticism occurs. Positive communication occurs by complimenting and expressing appreciation to others. I will listen and encourage others to express ideas and opinions.
• Value: Each person demonstrates pride in the physical appearance of all PIH Health properties. Behavior: Performance is acceptable when the initiative is taken to maintain a clean and safe environment. I conduct myself in a manner which respects and preserves equipment and the physical plant. I do not walk by spills, trash or unsafe conditions without assuring that they are attended to promptly by me or appropriate personnel.

Personal Qualities:

• Department Management to list.

Communication:

• Talking or hearing essential to communicate with patients and staff.
• Good communication skills; read, speaks and writes English fluently.