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.