Audit Specialist I

Health One Alliance•Dalton, GA

About The Position

The Audit Specialist is responsible for reviewing medical claims to ensure payments have been processed correctly and in accordance with the Company’s policies and procedures. This position analyzes data used in settling claims to determine the validity of payment of claims and reports overpayments, underpayments, and other irregularities.

Requirements

High School Diploma or GED required
In-depth knowledge of medical billing and coding including ICD-10, CPT4 Coding, HCPCS and medical terminology
A minimum of four years’ work and/or educational experience in the healthcare industry
In-depth knowledge of Medical Claims processing
Knowledge of health insurance, HMO and managed care principles
Critical thinking skills to build efficiencies
Highly proficient in MS Excel and MS word
Ability to find and willingness to suggest solutions with little or no guidance
Strong Analytic skills
Detail oriented and organized
Prolonged periods of sitting at a desk and working on a computer.
Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities.
Must be able to drive a vehicle and daytime/overnight travel as required.
Drug Screen and Background Check Required

Nice To Haves

Associates or bachelor’s degree preferred
Medical Coding or Medical Auditing Certification preferred

Responsibilities

Performs low to moderate audits of medical and dental claims as assigned by the Claims Quality Auditor Supervisor.
Utilizes healthcare experience to identify any possible errors including but not limited to code edits, industry standard guidelines, provider contracts and benefit limitations
Effectively utilizes audit tools.
Reprocesses claims to apply appropriate payment based on audit findings; this would include individual claims and batch claim reprocessing.
Creates and audits overpayment request letters.
Researches and resolves escalated audit issues in a professional, accurate and timely manner
Acts as a liaison with other departments regarding audits.
Tracks and reports issues to resolve any underlying system and/or benefit inaccuracies
Assist with monitoring of audit policies for accuracy and reports inaccuracies to management
Assists in the development and implementation of policies and procedures related to audits
Assists with the research and resolution of audit appeals
Effectively handles multiple, concurrent, projects.
Meets assigned deadlines and works under minimal supervision and with all levels of staff and management.
Maintains required productivity standards.
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned