Claims Auditor, Health Plan

Sanford Health•Marsh Security Hlth Plan, WI

4d•$18 - $28•Remote

About The Position

The Claims Auditor is responsible for performing payment, procedural accuracy, turnaround time, compliance and operational audits on claims as directed by management. The Claims Auditor has working knowledge of the overall aspects of claim processing. Responsibilities include applying effective, appropriate and efficient audit procedures in collecting, analyzing and reporting concise and relevant findings.

Requirements

High school diploma or equivalent required.
Successful completion of the following courses per departmental procedures,within one year of hire required: current procedural terminology (CPT), current international classification of diseases (ICD), health care procedure coding system (HCPCS) and medical terminology.
Three years of experience related to health insurance claim processing required.
Three years of experience related to CPT/HCPCS and current ICD coding.
Demonstrated proficiency with analytical problem solving, written and oral communications and the Microsoft Office Suite.
Working knowledge of anatomy & physiology.

Nice To Haves

Associates degree in business, medical or related field preferred.
Successful completion of the following courses per departmental procedures at time of hire preferred: current procedural terminology (CPT), current international classification of diseases (ICD), health care procedure coding system (HCPCS) and medical terminology.
One year experience in claims auditing preferred.
Certified Professional Coder (CPC) or Certified Professional Coder – Payer (CPC-P) certification awarded by the American Academy of Professional Coders (AAPC) at time of hire preferred.

Responsibilities

Develops and maintains a knowledge base of CPT coding guidelines, ICD codes, healthcare common procedure coding system (HCPCS) codes, use of modifiers, documentation guidelines, CMS policy, Medicaid rules, and other reimbursement guidelines, to review claims for accuracy, compliance, proper billing and ensure adherence to insurance policies and regulations.
Ability to utilize plan documents to ensure appropriate claim benefit application and coverage.
Develops and maintains thorough knowledge of the Audit application and claims processing systems to efficiently complete assignments and accurately enter data regarding audits into the auditing database.
Conducts monthly audits of pre-pay and post-paid claims to verify accuracy of processing, financial, procedural and turnaround time.
Investigates and reports claim variances to the appropriate staff for correction.
Conducts focused or ad-hoc audits, as determined by business needs.
Reviews medical records to determine the appropriateness of medical charges on claims that are chosen for complex audit review.
Analyzes and resolves complex claim processing problems, to ensure timely resolution of questions, audits or system issues.
Analyzes claim errors and provides reports to management to improve processes, editing or claim workflows.
Other duties as assigned.