Location: Orange, California US
Job Number: 1841
Position Title: Claims Auditor
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.
·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.
·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.
Location City: Orange
Location State: California
Community / Marketing Title: Claims Auditor
Who is Alignment Healthcare?
- Socially responsible
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- Concierge care
- 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.