Claims and Call Auditor (Call Center QC)

CHS-posted about 1 year ago
Full-time • Entry Level
Clearwater, FL
Food Manufacturing
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The Claims & Call Auditor is responsible for auditing processed medical insurance claims and customer service calls to ensure their validity, accuracy, and compliance with relevant policies, procedures, and regulations. This role involves conducting various types of audits, preparing reports, and maintaining knowledge of regulatory requirements in a call center environment.

  • Perform random audits, target audits, and audits for claims exceeding payment authority limits.
  • Audit recorded customer service calls.
  • Ensure compliance with company policies, procedures, guidelines, and federal and state regulations.
  • Prepare written audit reports based on findings and communicate them with leadership.
  • Identify patterns, trends, and variances related to claims and calls and provide feedback to the Manager.
  • Maintain up-to-date knowledge on regulatory requirements associated with billing and claims processing.
  • Review Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) for proper benefit code determination.
  • Participate in all aspects of the organization's Compliance Program.
  • Adhere to the policies and procedures of PFC Shared Services.
  • Maintain strict confidentiality of client, company, and personnel information.
  • Prior auditing experience is preferred.
  • Knowledge of medical terminology.
  • Knowledge of medical coding systems.
  • Knowledge of Medicaid/Medicare Guidelines.
  • Knowledge of billing rules and regulations.
  • Strong organizational and interpersonal skills.
  • Excellent written and verbal communication skills.
  • Detail-oriented.
  • Ability to multi-task and work independently.
  • Bilingual fluency in English/Spanish is a plus.
  • Experience in medical customer service, quality assurance, or insurance training is preferred.
  • Health Insurance
  • Dental Insurance
  • Vision Insurance
  • Life Insurance
  • Paid Time Off
  • Paid Holidays
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