Job Title: Claims Auditor (Internal)
Reports To: Claims Operations Director
Supervised By: Claims Operations Director
Rate: Contract to Permanent - $30.00 per hour + full benefit plan offered
General Purpose
The Claims Auditor is responsible for supporting the Managed Care Organization’s commitment to 100% quality effectiveness by ensuring all claims are processed accurately, using appropriate adjustment codes and payment rates. This role involves auditing claims for compliance with federal and state regulations, contractual provisions, and internal policies, with a focus on Medicare lines of business.
Duties and Responsibilities
- Maintain proficiency with federal claims processing requirements.
- Ensure adherence to AB1455 Claims Settlement Practice and Dispute Resolution regulations.
- Accurately apply rates for CMS 1500 and CMS 1450 (UB04) claims, specific to Medicare.
- Verify rate application for outpatient and inpatient facilities, ambulatory surgery centers (ASCs), and other payment methodologies supporting Medicare.
- Audit claims for compliance with contractual provisions, regulatory guidelines, and company policies.
- Perform “pre” and “post” audits for claims examiners at all levels to identify deficiencies and improve quality.
- Provide guidance and direction to Claims Examiners to enhance departmental and individual performance.
- Utilize Crystal Reports to identify errors in processed claims before check runs.
- Generate valid reports and deliver monthly production quality updates to the Claims Operations Director.
- Maintain confidentiality of individual examiner results, adhering to Standard Operating Procedures (SOP).
- Recommend improvements to audit procedures and ensure consistency in processes throughout the year.
- Comply with CMS (Medicare) timeliness guidelines, such as 30 calendar days for non-contracted Medicare claims and 60 calendar days for contracted Medicare claims.
- Use and apply Benefit Matrices and Division of Financial Responsibility (DOFR).
- Execute additional claims-related duties as assigned.
Qualifications
- Minimum of three years’ experience in claims processing or auditing, with internal auditing experience preferred.
- Demonstrated ability to work effectively with minimal supervision.
- Proficient knowledge of medical terminology, CPT, ICD-9, revenue codes, and HCPCS codes.
- Strong verbal and written communication skills.
- Excellent organizational and interpersonal skills.
- Experience with EZ-CAP and other claims examining system modules and functionalities.