Claims Auditor

SUMMARY:Performs routine and moderately complex audits on paper and electronic claims to identify inaccurate claims adjudication. Will run and audit exception audit reports on a daily basis. Researches claim processing problems and errors to determine their origin and appropriate resolution. Summarizes findings and recommendations in reports for feedback to examiners and distributes results to management. Participates in communication with claims department management regarding results of claims audit process in order to improve claims processing accuracy. Tracks quality of claims processing and logs data into various spreadsheets. Ensures claims adjudication is in accordance to HCFA and DMHC regulations as well as departmental guidelines. Provides qualified data for incorporation into training programs, policies and procedures. Completes special projects as needed

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

1.Support the Claims Department in resolving clinical issues related to the payment of medical bills.

2.Establish effective ongoing relationships with community hospitals and providers to gain access to patient medical records and to negotiate settlement of inappropriately billed charges.

3.Review all bills over a specified dollar amount and others as requested for appropriateness of charges and pursues adjustments as warranted.

4.Perform special projects, reconciliation, research and analysis related to utilization and cost of medical services.
REQUIREMENTS
QUALIFICATION REQUIREMENTS:
High School diploma or equivalent required. Good mathematical and data collection skills. Excellent oral/written communication skills including presentation abilities. Ability to interact with all levels of company. Strong analytical and problem solving skills. General knowledge of automated claims processing systems, including data entry and resolution. Three years claims processing experience. Ability to apply and interpret provider and healthplan contracts. Thorough knowledge of claims adjudication procedures, CPT, RVS, ASA, HCPCS, ICD-9 coding, medical policy (authorizations) guidelines, contract pricing and authorization application, member eligibility/benefits, and COB used for processing claims.

EDUCATION and/or EXPERIENCE:
Two years experience in customer service dealing with phone and correspondence inquiries from providers, and beneficiaries, and/or directly related experience.

LANGUAGE SKILLS:
Ability to interact with all levels of company. A minimum of three years claims processing experience - preferably in a managed care, health plan or medical group environment. General knowledge of automated claims processing systems, including data entry and resolution. Ability to apply and interpret provider contracts. Thorough knowledge of claims adjudication procedures, CPT, ICD-9 coding, medical policy guidelines, contract pricing information, and member benefits used for processing claims.