Senior Claims Auditor

Senior Claims Auditor

Department: Ops - Claims Ops

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Stacy Brouhard

Compensation: $70,000 - $83,000 / year

Job Title:

Senior Claims Auditor

Department:
Ops - Claims Ops

About the Role:

We are currently seeking a highly motivated Senior Claims Auditor. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.

Audit & Oversite

• Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits
• Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit
• Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines
• Respond to preliminary results by the due dates
• Requires the ability to respond to the corrective action plan timely and address the root cause appropriately as well as remediate the deficiency
• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows
• Handle complex and urgent audit projects from external provider and internal departments
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests

Audit Documentation/Reconciliation

• Accurately document the underpayments and over payments into the audit database
• Assist management with analyzing Claim error trends
• Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer

Collaboration

• Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution
• Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members

• Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures required
• Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc
• Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
• Possess working knowledge of NCQA, DHS and HCFA standards
• Knowledge of medical terminology combined with detail knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD
  10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recovery
• Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
• Must possess the ability to effectively present information and respond to questions from managers, employees, customers
• Must possess advanced reasoning and problem-solving abilities and planning skills
• Ability to multi-task, prioritize and work in a fast-paced environment under minimal supervision
• Proficient in Excel to include the ability to create and revise Excel spreadsheets to provide accurate and clear reports
• A High School Diploma or Equivalent
• Previous 2 years’ experience as Medical Claims Auditor or 7 years previous experience examining Claims
• Strong independent decision-making, influencing and analytical skills
• Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines

You’re great for the role if:

• Bachelor’s degree preferred

• Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office…