Risk Pool Auditor


Responsible for reviewing claims paid in Shared and Dual Risk Pools, monitor and maintain the files audited, submitted for disputes and responses from outside entities. Responsible for the accuracy and integrity of the Hospital claims paid by MPM.  Ensures interpretation and compliance with the appropriate Division of Financial Responsibility (DOFR), while developing and maintaining a working knowledge of the statues and laws relating to billing, claims payments and claims adjudication. Prepare files for claims dispute submission to health plans and other outside entities. Works under the supervision of the Auditing & Recoveries Supervisor.

Duties and Responsibilities

  • Review, Track and Analyze Risk Pool Summaries
  • Audit Risk Pool Detail and submit disputes to Health Plan or Cap Hospital
  • Review Response from Health Plan or Cap Hospital for accuracy
  • Ensure that disputes agreed to are credited back to the pool
  • Ensure pool settlements are paid timely

Minimum Job Requirements

High school diploma or GED; at least 2 years’ experience with Hospital claims processing and/or billing.  AAPC Coding certification highly preferred.

Knowledge, Skills and Abilities Required:

  • Strong written and oral communication skills.
  • Knowledge of medical terminology and medical claims coding
  • Ability to analyze, interpret and prepare DOFR’s and reports.
  • Proficiency with Microsoft Office Programs; primarily Word and Excel 2013 or higher
  • EZ-CAP® knowledge a plus.

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