Claims Auditor

Overview

To accurately perform concurrent, retrospective, and special audits on all level I claim types for all Partnership lines of business.

• Perform concurrent and retro claims audits on new Claims examining staff and on claims processed by existing Claims staff as outlined in Claims Operating Instruction Memorandums for all lines of business.
• Document audits and report all audit outcomes following the Partnership Claims Operating Instruction Memorandums on claims auditing.
• Maintain current knowledge of Partnership Claims Policy and Procedures for all lines of business, Medi-Cal Provider Manual, Title 22 regulations, Knox Keene regulations, and CMS Medicare regulations.
• Perform special claims audits as assigned.

• Participate in special projects and assignments as required.
• Other duties as assigned.

Education and Experience
Minimum two (2) years of claims examining experience and completion of Partnership Claims training; or equivalent combination of education the experience.

Special Skills, Licenses and Certifications
Familiar with Medi‑Cal and/or managed care claims processing. Knowledge of CPT, HCPCS procedure coding, and ICD-9/ICD-10 diagnostic coding. Typing speed 30 wpm and proficient use of 10-key calculator. Familiar with AMISYS or similar claims systems. Understanding of claims examining requirements. Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies
Excellent oral and written communication skills. Ability to effectively exercise good judgment within scope of authority and handle sensitive issues with tact and diplomacy. Ability to work on multiple tasks within established time frames and sometimes conflicting priorities. Good organizational skills with ability to maintain accurate records and documentation of actions and decisions.

Ability to use a computer keyboard. More than 60% of work time is spent in front of a computer monitor. When required, ability to move, carry or list objects of varying size, weighing up to 5 lbs.