Claims Auditor
Claims Auditor
Posted on :
11-04-2025
Employer Active
1 Vacancy
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Yearly Salary
$ 80000 - 90000
Vacancy
1 Vacancy
Posted on :
11-04-2025
Job Description
POSITION DESCRIPTION
Under general direction this position is responsible for supporting total quality methods processes and procedures for the claims department and call center. This position will help preserve service excellence through monitoring and assessing customer interactions documenting agent performance strengths and weaknesses highlighting immediate compliance issues assisting in generating standard process measurement reporting and developing quality guidelines. The candidate will also be responsible for researching complex claim issues as identified by internal and external sources.
ESSENTIAL FUNCTIONS
- Conduct prepay and postpay audits to ensure accurate claims payments and denials
- Ensure regulatory compliance and overall quality and efficiency by utilizing strong working knowledge of claims processing standards
- Work closely with delegated claim processor(s) to ensure errors are reviewed and corrected prior to final payment
- Work assigned claim projects to completion
- Provide a high level of customer service to internal and external customers; achieve quality and productivity goals
- Escalate appropriate claims/audit issues to management as required; follow departmental/organizational policies and procedures
- Maintain production and quality standards as established by management
- Participate in and support adhoc audits as needed
- Conduct customer service postaudits for both inbound and outbound calls
- In Claims Resolution the employee will analyze claims data to identify inaccuracies affecting providers respond to provider inquiries and collaborate with various departments to rectify processing issues
- Respond to provider inquiries through written or verbal communication and investigate processing inaccuracies
- Serves as a liaison with other areas and business units
KNOWLEDGE SKILLS AND ABILITIES
Education: High School Diploma/GED required
- Experience: Two 2 years experience with complex claims processing and/or auditing experience in the health insurance industry or medical health care delivery system or
- Two 2 years experience in a managed healthcare environment related to claims processing/audit or
- Two 2 years experience with standard coding and reference materials used in a claim setting such as CPT4 ICD10 and HCPCS or
- Two 2 years experience with CMS requirements regarding claims processing and other complex claim processing rules and regulations or
- Two 2 years experience processing/auditing claims for Medicare plan
Licenses/Certifications: N/A
Other Job Requirements: Able to perform basic to intermediate level of competence with various computer software applications including MS Outlook Word Excel Access and PowerPoint. Able to effectively communicate with internal staff facility administration and external customers. Full command of the English language both verbal and written. A home office that is HIPAA compliant for all remote or telecommuting positions as outlined by the companys policies and procedures.
- Proficient in processing/auditing claims for Medicare and Medicaid plans
- Strong knowledge of CMS requirements regarding claims processing and other complex claim processing rules and regulations
- Current experience with both Institutional and Professional claim payments
- Knowledge of automated claims processing systems
CHP Values and Benefits
- Integrity:To do the right thing even when nobody is watching.
- Teamwork:Collaborate and support each other in achieving a common goal.
- Accountability:To take responsibility for our successes and failures and to hold ourselves and others to highstandards.
- Patientcentered:To identify patient needs and provide optimal patient care.
- Compassion:To be empathetic toward the needs of our clients patients and coworkers.
Correctional Health Partners offers a professional atmosphere competitive salaries and a full range of benefits. Benefits we provide include:
- 401(k) plan.
- Medical dental and vision benefits.
- Flex spending medical and dependent care plans are available.
- Paid time off up to 28 days per year based on tenure and position.
- Paid holidays: we recognize 9 holidays.
- Education tuition reimbursement.
Salary Range: $80000.00 to $90000.00 Annually dependent on experience
Correctional Health Partners is an Equal Opportunity Employer.All qualified applicants will receive consideration for employment without regard to race color religion sex age national origin protected veteran status disability status sexual orientation gender identity or expression marital status genetic information or any other characteristic protected by law.
Employment Type
Full Time
Key Skills
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