Claims Appeals Auditor

Regal Medical Group•Los Angeles, CA

3d•$23 - $25•Onsite

About The Position

This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHS. This position includes the responsibility for routine hospital and professional audits, complex audits on individual or random, training and focused claims to identify exceptions to established claims adjudication requirements for claims processing, payment and procedural accuracy. In addition, this position is responsible to assist with eligibility identify (e.g. COB, ESRD) and Letters of Agreements as required. To maintain in strict confidence, all member, provider and Health Plan information to which Claims Auditing Specialist has access.

Requirements

High School graduation.
Possess strong knowledge of CPT, ICD, HCPCS, DRG coding and claims adjudication for hospital and professional claims.
Knowledge of medical terminology.
Basic level proficiency with Microsoft Office applications including Word, Excel, PowerPoint.

Nice To Haves

Prefer 5 years previous experience with adjudication all types of claims.

Responsibilities

Performs routine and complex audits on individual, random, trainee and focused claims to identify exceptions to established claims adjudication requirements for both Pre-EOB and post payment.
Perform 1st level audit based on reports and run Virtual Examiner Reports prior to each check run.
Researches claim processing problems and errors to determine their origin and appropriate resolution.
Researches member activity to identify Coordination of Benefits, Third Party Liability, Out-of-Area and Workers’ Compensation as identified through member admissions, authorization process or claims activity
Notify management immediately if any report processing deadlines cannot be met.
Identify, proactively through auditing and internal reporting, negative and positive trends and initiate recommendations for change
Analyze data processing reports and make necessary corrections or adjustments
Assist with training of claims adjudication staff as needed
Assist manager with follow-up on any problems or questions related to the audit results
Other duties as assigned