Claims Auditor conducts audits for management to assess effectiveness of controls, accuracy of claims records and payments, efficiency of claims operations, and to recover claims overpayments. Audits all paid and denied claims to identify processing errors and coordinates with management to develop processing standards. Identifies and reports suggestions for operational efficiency improvements to management. Implements auditing guidelines and processes and creates policies and procedures for the internal auditing process. Implements random auditing process or hard copy claims. Develops forms for notification of audit results to claims staff. The Claims Auditor develops and runs claims processing system reports to assist in periodic monthly audit reporting. Claims Auditor also assists in the administration of recoveries for the overpayment of claims.
Duties and Responsibilities
- Analyze, process, research, adjust and adjudicate claims with the use of accurate procedure/revenue and ICD-9 codes, under the correct provider and member benefits, i.e. co-payment, deductible, etc.
- Review and process facility (UB-04) and professional claims (CMS-1500)
- Process claims based on contractual agreements, health plan division of financial responsibility, applicable regulatory legislature, claims processing guidelines and client groups’ and company policies and procedures.
- Process Medicare member claims based on DMHC and DHS regulatory legislature.
- Respond to and resolve provider and health plan claims inquiries and give resolution in a timely manner.
- Review services for appropriateness of charges and apply authorization guidelines during claims processing.
- Monitor and track age, pended, and open reports to maintain timeliness in claims processing based on individual work allocation report.
- Maintain quality and productivity standards, teamwork, and comply with company/administrative guidelines.
- Participate in special projects, complete tasks assigned by management and attend meeting/conference call as necessary.
- Must have at least 3 years of applicable healthcare claims adjudication experience within the managed care industry for a level I or II and at least 4 years for Senior level claims.
- Candidates with multi-product line claims adjustment experience, preferred.
- Must be familiar with ICD-9, HCPCS, CPT coding, APC, ASC and DRG pricing, CMS, DMHC regulations, facility and professional claim billing practices.
- Must possess proficient filing, general clerical, verbal and written communication and presentations skills.
- Must be able to problem-solve, 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 Claims adjudication software, preferred.
- Ability to type with accuracy and speed of a least 35 wpm.
- Associate's degree (A. A.) or equivalent from two-year college or technical school; some college courses, or six months to one year related experience and/or training; or equivalent combination of education and experience.