Location: Orange, California US
Job Number: 1859
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.
·Reviews claims for statistical and payment accuracy. Ensure appropriate payments or denials, and use of adjustment or reason codes are correct
· Identifies root cause of errors and work with internal departments for resolution
· 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.
· Prepares and issue audit reports which include audit findings, scores and corrective actions
· Monitors completion of corrections
· Assists with training of claims examiners based on identified errors
· Submit monthly audit reports to Management.
· 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 related duties as assigned.
1. Minimum Experience:
· 3+ years medical claims auditing experience in HMO or IPA/Medical Group setting required, preferably Medicare claims
· 3-5 years of experience in examining all types of medical claims, preferably Medicare claims
· Experience working with Provider Dispute and Appeals
· Proficiency in Microsoft Office programs (Excel, Access, Word), intermediate level
· Experience using claims processing systems (EZCAP preferred).
· Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
· Working knowledge of different claims payment methodologies and claim editing guidelines
· Familiarity with CMS regulations related to Part C claims
· Proven problem- solving skills and ability to translate knowledge to the department
· Bachelor’s Degree in Business or related field (preferred)
· Ability to multitask
· Strong organizational skills
· Attention to detail
· Ability to use 10 key
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.