Auditor Claims BCI

Highmark Health•Washington, NV

4d•$22 - $33

About The Position

The Auditor Claims BCI position ensures all claims are handled according to internal operating and administrative procedures. This role involves reviewing plan wording, monitoring audit workflows for timely turnaround, and maintaining workload standards. The auditor will record results in the audit tool for monthly reporting, partner with the supervisor on training, and conduct one-on-one coaching with the claims team, especially trainees. Recommendations for dollar authorization will be provided based on audit statistics and team member interactions. The position also assists the supervisor with specialized audits, maintains knowledge of benefits and regulations, and provides expertise on complex claim situations. Communication skills are essential for liaising with clients, management, and peers. The role manages the refund, void, and stop payment process, guides the claims team on processing questions, and assists with system upgrade testing. Other duties as assigned may also be part of the role.

Requirements

5 years prior medical dental, vision, FSA and HRA claims processing experience.
Comprehensive understanding of CPT, HCPCS, ICD9 and ICD10 medical coding.
Strong attention to details along with organizational skills.
Excellent problem solving with the ability to work in a fast paced production environment.
Excellent communication skills both verbal and written.
PC navigation skills for Professional work environment.
Basic MS Excel.
Basic MS Word.
Ability to use judgement to make sound decisions referencing all available resources.
Ability to work independently and also as part of a team.
Ability to research and seek assistance through all available resources, to ensure resolution on claim audits.
Must be able to multi-task and follow up at appropriate intervals.
Raise concerns to the management team on situations and/or issues in a timely manner.

Nice To Haves

Associate Degree

Responsibilities

Ensure all claims are handled according to all internal operating and administrative procedures along with reviewing plan wording for each individual employer group, which should include the plan document, amendments, matrices and benefit summary.
Monitor workflow of audits to ensure timely turnaround time. Identify the performance guarantee group’s audits to meet the strict guidelines for turnaround time.
Maintain workload in accordance with the quality and production standards defined for the auditing team.
Record results in the audit tool for monthly reporting.
Partner with the supervisor to create and conduct training sessions for issues identified by the management team.
Conduct one on one coaching with the claims team especially the trainee staff.
Provide recommendation for dollar authorization for claims team members based on audit stats and interaction with individual claim team members.
Assist supervisor with specialized audits for the SOC process, carrier, vendor and employer audits as necessary.
Maintain detailed knowledge of benefits, state regulations, federal guidelines and system upgrades.
Review and provide expertise to the claims team with complex claim situation/issues by using all resources to render a sound decision.
Utilize excellent written or verbal communication skills to liaise with clients, management, peers and other areas within the organization.
Manage the refund, void and stop payment process.
Provide guidance to the claims team with questions on all aspects of claims processing.
Assist with system upgrade testing.
Handle other duties as assigned.

Benefits

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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