Claim Auditor I

Cook Children's Health Care System•Fort Worth, TX

11d•Onsite

About The Position

The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle.

Requirements

Associates degree or a minimum of 5 years of claims/audit experience.
Experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment preferred.
7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding.
Strong organizational skills.
Problem-solving skills.
Decision-making skills.
Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs.
Microsoft Office skills including Word, Excel and Access.
Excellent customer service skills with ability to explain complicated benefit issues to staff and providers.

Nice To Haves

Experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment.

Responsibilities

Auditing behavioral and medical claims for Texas Medicaid and CHIP programs.
Conducting post claims reviews on posted claims to ensure quality metrics are met.
Auditing a set claim sampling on a monthly basis of routine to moderate complexity, including paper and electronic claims.
Ensuring claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding, and system configuration.
Preparing audit reports that may include UB-1450 and HCFA CMS 1500 claim forms for various claim types.
Pre-auditing high dollar claims to ensure payment accuracy before release.
Communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines.
Communicating audit results to the Claims Department.
Performing all job functions in accordance with HIPPA and security rules related to protected health information.
Maintaining a thorough understanding of the claims life cycle.