Alignment Healthcare is a population health management company dedicated to changing the way health care is delivered in the United States. We are a fast-growing, highly dynamic organization that isn’t content with the status quo. We are looking for dedicated, innovative individuals who thrive in a fast-paced environment to join our team and help us carry out our vision - that is, to lead a movement that transformationally improves health care.

Join us today and we will give you every opportunity to succeed.

Claims Auditor

Location: Orange, California US

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Job Number: 1841

Position Title: Claims Auditor

External Description:

The Claims Auditor reports directly to the Sr. Director of Claims (“Director”). The auditor is responsible for reviewing claims processed by examiners based on provider and health plan contractual agreements and claims processing guidelines.  Follows all internal processes and procedures to ensure claims audit activities are handled in accordance with departmental and company policies and procedures. Excellent knowledge of claims processing rules and Medicare regulatory requirements.  Maintains production standards as established by departmental management to meet quality requirements, ensure payment integrity, identify root cause and training opportunities.

General Duties/Responsibilities:

·Performs claim review of data entry, processing and adjudication of claims and communicates deficiencies to Director, claims examiners, trainer, analyst and other department management.

·Identifies root cause and works with internal departments regarding system defects and escalates issues to ensure resolution as needed.

·Reviews claims for statistical and payment accuracy.

·Finalizes claims for denial of payment.

·Review claims for fraud, waste or abuse and notifies management of such findings.

·Updates systems, tracking tools or other documentation methods as needed.

·Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement.

·Ensure the privacy and security of PHI (Protected Health Information) as outlined in the department policies and procedures relating to HIPAA Compliance.

·Foster good corporate relations by practicing good customer service principles (i.e., positive attitude, helpful, etc.).

·Other Duties as Assigned.

Supervisory Responsibilities:

None.

Minimum Requirements:

·High School Diploma.

·5+ Years experience in Medicare claims auditing and/or processing.

·Knowledge of claims processing systems (EZCAP preferred).

·Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.

·Experience in processing/adjudicating medical, hospital and other facility claims.

·Proven problem solving skills and ability to translate knowledge to the department.

·Working knowledge of Microsoft Office Products.

·Background in Medicare Advantage and/or Medical Group/IPA claims environment preferred.

·Ability to multitask.

·Strong Organizational Skills.

·Attention to Detail.

·Ability to use 10 key.

·Familiarity with CMS regulatory requirements


Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

1.      While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2.      The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

 

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Claims Auditor

Company Profile:

Who is Alignment Healthcare?

  • Socially responsible
  • Technologically enabled
  • Concierge care
  • Transformation
  • Servant leadership

We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.

We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.

EEO Employer Verbiage:

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact careers@ahcusa.com.

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