Claims Auditing Specialist IV

Kaiser Permanente • Atlanta, GA

237d

About The Position

Investigates claims reviews/appeals by performing audits to validate conformance with policies and payment methodologies and analyzing data to identify problems. Evaluates audit processes by developing/testing criteria to ensure processes are compliant, conducting assessments to ensure data and quality standards are maintained, and providing feedback. Documents claims outcomes by determining coverage eligibility, and preparing reports of findings, and offering thoughts on resolving the issue. Facilitates the resolution of payment discrepancies by using strategies, responding to findings, addressing issues, and coordinating audits. Contributes to compliance processes by developing/reviewing training and procedure requirements, developing instructional material, assigning work, and participating in trainings. Facilitates efforts to optimize system improvements by identifying/investigating issues, researching and providing feedback on process efficiencies, generating reports/reporting systems, and suggesting policy changes to improve processes.

Requirements

• Minimum three (3) years medical claims auditing experience.
• Minimum of one (1) year of regulatory experience.
• High School Diploma or GED, or equivalent and a minimum of four (4) years of experience in health care, vendor contracts, benefits configuration, claims processing or a directly related field OR Minimum five (5) years of experience in health care, vendor contracts, benefits configuration, claims processing or a directly related field.

Nice To Haves

• Knowledge of Data Entry
• Understanding of Benefit Plans
• Familiarity with Insurance Coding
• Experience with Internal Audit Processes
• Skills in Claims Adjudication
• Ability in Contract Review & Claims Validation
• Strong Presentation Skills

Responsibilities

• Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members.
• Builds relationships with cross-functional/external stakeholders and customers.
• Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers.
• Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses.
• Leads by influencing others through technical explanations and examples and provides options and recommendations.
• Adopts new responsibilities; adapts to and learns from change, challenges, and feedback.
• Demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes.
• Facilitates team collaboration to support a business outcome.
• Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions.
• Encourages team members to adapt to and follow all procedures and policies.
• Collaborates cross-functionally and/or externally to achieve effective business decisions.
• Provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate.
• Monitors progress and results.
• Supports the development of work plans to meet business priorities and deadlines.
• Identifies resources to accomplish priorities and deadlines.
• Identifies, speaks up, and capitalizes on improvement opportunities across teams.
• Uses influence to guide others and engages stakeholders to achieve appropriate solutions.
• Documents the resolution and reporting of claims outcomes.
• Evaluates audit processes by developing and testing audit criteria.
• Conducts quality assessments of payment and audit processes.
• Investigates claims reviews and appeals by performing comprehensive audits of medical claims payment and invoice data.
• Analyzes data to identify problems of a moderate scope relating to service utilization.
• Contributes to efforts to monitor and optimize system improvements.
• Identifies technology and operational process efficiencies.
• Generates standard reports and/or notifications.
• Makes changes to standard and non-standard policy and implements strategies to improve internal processes.
• Contributes to compliance working processes by developing training requirements.
• Participates in approved trainings on topics related to claims systems, processes, data, and policies.
• Supports the resolution of payment discrepancies for services.

What This Job Offers

• Industry: Ambulatory Health Care Services
• Education Level: High school or GED