Claims Auditor (50476)

Job Description Summary

This position reports to the Supervisor of Payment Integrity and performs in-depth audits to ensure existing health (medical/dental) benefit plans of Western Growers Assurance Trust and Pinnacle Claims Management, Inc. clients are in compliance with the respective employers' summary plan descriptions.

Duties And Responsibilities

Claims Auditing

• Perform routine and moderately complex audits on paper and electronic claims for payment integrity in alignment with regulatory and timelines standards, business policy, and contract terms.
• Ensure appropriate coding and system configuration of claims with the ability to extract and audit exception audit reports.
• Research claim processing problems and errors to determine their origin and appropriate resolution.
• Prepare reports and summarize observations and recommendations for management.
• Participate in communication with management regarding trends in order to improve claims processing accuracy and documented business rules for incorporation into training programs, policies, and procedures.
• Perform special project audits and reviews as requested by other departments/regions.

Claims Department Support

• Identify and escalate issues related to instructional material that is inaccurate, unclear or contains gaps and provide recommendations for correction of this material.
• Confer with management to assess training needs in response to changes in policies, procedures, regulations, and technologies.
• Provide technical support, training assistance, and expertise to claims staff or other departments as determined through audit findings.
• Participate in claims staff performance improvement plans by providing additional auditing and/or basic coaching as needed.Participate in departmental error logs analytics and includes the findings in training preparations.
• Provide technical support, training assistance, and expertise to claims staff or other department as determined through audit findings.
• Support and assist management team in updating department policies and guidelines.
• Assist with user acceptance testing (UAT) for new system enhancements.

Process Improvement

• Prepare monthly audit trend report for management that reflects primary errors, the root cause for the errors, and suggested improvement plans to improve the accuracy of claims processing.
• Participate in departmental error logs analytics and include the findings in training preparations.
• Provide process improvement recommendations to management based on trends identified in auto-adjudication claim errors.
• Identify staff training needs, support training development, and coordinate ongoing or ad-hoc training.

Other

• Utilize all capabilities to satisfy one mission - to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA- required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).All other duties as assigned.

Physical Demands/Work Environment

The physical demands and work environment described here represent those that an employee must meet to perform this job's essential functions successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.

Qualifications

• BS/BA degree preferred and a minimum of one (1) to three (3) years of recent experience as a medical/dental claims auditor, preferred.
• At least three (3) years' experience processing group health claims, highly desired.
• Knowledge of the Patient Protection and Affordable Care Act (PPACA), Health Insurance Portability and Accountability Act (HIPAA), Consolidated Omnibus Budget Reconciliation Act (COBRA), California-COBRA, and Employee Retirement Income Security Act (ERISA) regulations.
• Knowledge of Current Procedural Terminology (CPT) and International Statistical classification of Diseases and Related Health Problems (ICD-10 & ICD-9) and medical terminology.
• Exceptional understanding and interpretation of summary plan descriptions of employee medical/dental benefits.
• Good ability to interpret provider contracts.
• Proven ability as a self-starter to manage timelines and commitments.
• Proficient in end-user software, e.g., word-processing and spreadsheets.
• Exceptional written and verbal communication skills.
• Strong knowledge of business math.
• Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.
• Home router with wired Ethernet (wireless connections and hotspots are not permitted).
• A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)
• A functioning smoke detector, fire extinguisher, and first aid kit on site.