Overview: The Claims Auditor will be responsible for the accurate review and auditing of claims that are adjudicated by the system and the Claims Examiners.
The auditor will suggest process improvements to management and act as a resource of information to all staff.
The Claims Auditor will identify overpayments and coordinate with the Claims Recovery Unit.
Responsibilities: Audit claims as it relates to the appropriate Federal and State regulations based on the member’s Line of Business.Read and interpret DOFRs as it relates to the claim in order to ensure that group is financially at risk for payment.Read and interpret provider contracts to ensure payment accuracy.Read and interpret Medi-Cal and Medicare Fee Schedules.Utilize auditing tools to identify and determine accuracy of claims payments (prospectively and retrospectively).Coordinate with internal departments for any issues relating to provider, fee schedule, eligibility, authorization, or system issues.Complete appropriate documentation for tracking/trending of data in order to identify system issues and remediation.Provide regular feedback to the Claims Management team concerning process improvement opportunities, or any training opportunities relative to adequacy of file investigation/ development in advance of the recovery effort.Coordinate with the Recovery Department for any identified overpayments.Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.Other duties as assigned.
Qualifications: HS Diploma or GED3 years of Claims Processing experienceMust be knowledgeable of Medi-cal regulationsPreferred knowledge of Medicare and Commercial rules and regulationsKnowledge of medical terminologyMust have an understanding to read and interpret DOFRs and Contracts.Managed Care conceptsMust have strong organizational and mathematical skills.