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 include 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 include safeguarding and preserving the confidentiality of patient's protected health information in accordance with State and Federal (HIPAA) regulatory requirements, hospital and departmental policies; ensuring a safe patient environment and adherence to safety practices per policy; utilizing the approved process to resolve biophysical, psychological, educational and environmental needs of patient/significant other when administering care; assisting the Claims Director in the training and education of the Claims department staff; coordinating the generation and review of claims audit, status and pending claims reports ensuring authorized claims are paid in accordance with company guidelines; investigating, processing and tracking payment adjustments including refunds, overpayments and underpayments; acting as a confidential and professional resource for group providers and other staff; acting as a resource for providers, members, insurance carriers, attorneys and co-workers, researching and responding to questions in a timely manner; creating, maintaining and generating system reports; interfacing with the Claims Director to ensure claims processing functions meet legal and contractual requirements with regards to health plan audits; preparing and presenting weekly and monthly reports reflecting staff and departmental quality statistics; reviewing and auditing member liability denials and Provider Dispute Resolution claims to ensure compliance with regulatory requirements and passing audit scores from health plans; performing other duties as assigned.
Teamwork/customer service responsibilities include displaying loyalty and pride in and upholding the confidentiality of patients, visitors, physicians, and co-workers; demonstrating commitment to open communication; demonstrating pride in the physical appearance of all properties.
Personal qualities include commitment to open communication.
Communication skills include talking or hearing essential to communicate with patients and staff; good communication skills; read, speaks and writes English fluently. Bilingual skills in Spanish/Chinese preferred.
Claims Auditor • Whittier, CA, United States
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