Claims Auditor

Job Description:

Claims Auditor will be responsible for auditing claims processed by Claims Examiners.

Responsibilities include, but not limited to:

• Maintain up-to-date knowledge of procedures for all ICD-10, CPT, HCPC codes including:
  • Contractual agreement rates
  • Health Plan procedures
  • Medicare and Medi-cal reimbursement
  • Claims processing guidelines
• Evaluate claims based on DMHC and DHS regulations
• Respond and resolve providers’ and health plans’ inquires in a timely manner
• Check for adjudication errors and present them to respective Examiner
• Present recommendations for improvements for Examiners
• Identify escalating issues to appropriate team(s) and management
• Monitor aging claims with reports to maintain timeliness
• Maintain quality and productivity standards
• Maintain a minimum audit-accuracy rate
• Participate in special projects
• Collect claim sample data to perform audits
• Reports and works closely with Claims Manager

• Bachelor’s degree in related field or AA degree with related experience
• Must have at least 5 years of applicable healthcare claims adjudication experience within a managed care industry
• Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC, and DRG pricing.
• Must be familiar with facility (UB-04) and professional (CMS-1500) claim billing practices.
• Must have good written and communication skills.
• Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment.
• Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and EZ-CAP. EZ-CAP 6X is a plus.
• Typing skills of a least 40 wpm.

• Medical Insurance
• Dental Insurance
• Vision Insurance
• Life Insurance
• 401K Matching
• Paid Time Off