CLAIMS AUDITOR

Trinity Health•Maywood, IL

3d•$21 - $33•Remote

About The Position

Position located in Westmont, Illinois - remote eligible. Benefit eligible (medical/dental) from the first day of employment. Perform Quality Auditing of Claim Adjudicators and Customer Service Representatives. Audit capitation deductions, preparing summary of findings and disputes to the various HMOs. Review and respond to Stat Fax/Past Due Claim (PDC) inquiries from the HMOs. Review claims for accuracy of information into the claims processing system and ensure Standard Operating procedures (SOPs) have been followed. Provide feedback to staff as errors are identified, including where procedures can be found on correct handling when appropriate. Work closely with Operations Manager to identify areas requiring additional training, either on an individual basis or overall. Review authorization/claim history to determine handling and appropriateness of deductions. Enter disputed deductions into Excel or Access, depending on the health plan. Review outstanding deductions and follow up with the health plan as needed. Update CHS files upon receipt of health plan’s response to indicate whether or not a credit was received. Research, document and respond to HMO inquiries within appropriate time frames to avoid future capitation deductions. Responsible for contacting HMO for copies of claims that are not in claims processing system and require entry/adjudication. Responsible for contacting providers when claims have been processed to verify status of accounts. Enhance department productivity by recommending improvements to the work flow processes and organizational structure. Contribute to team effort by accomplishing related results as determined by management. Attend meetings as necessary either internally or with the HMOs

Requirements

Associate Degree or 5-10 years of claims auditing and/or Managed care experience
3-5 years of previous job-related experience
Previous job related experience in a managed care environment, claims processing, claims auditing, analysis of claims errors.
Familiarity with managed care products.
Able to track errors and provide training if needed.
Ability to plan, coordinate and develop multiple projects

Nice To Haves

Bachelor Degree
AAPC certification
6-10 years of previous job-related experience
Certified Professional Coder (AAPC)
RHIA, RHIT and AAPC

Responsibilities

Perform Quality Auditing of Claim Adjudicators and Customer Service Representatives.
Audit capitation deductions, preparing summary of findings and disputes to the various HMOs.
Review and respond to Stat Fax/Past Due Claim (PDC) inquiries from the HMOs.
Review claims for accuracy of information into the claims processing system and ensure Standard Operating procedures (SOPs) have been followed.
Provide feedback to staff as errors are identified, including where procedures can be found on correct handling when appropriate.
Work closely with Operations Manager to identify areas requiring additional training, either on an individual basis or overall.
Review authorization/claim history to determine handling and appropriateness of deductions.
Enter disputed deductions into Excel or Access, depending on the health plan.
Review outstanding deductions and follow up with the health plan as needed.
Update CHS files upon receipt of health plan’s response to indicate whether or not a credit was received.
Research, document and respond to HMO inquiries within appropriate time frames to avoid future capitation deductions.
Responsible for contacting HMO for copies of claims that are not in claims processing system and require entry/adjudication.
Responsible for contacting providers when claims have been processed to verify status of accounts.
Enhance department productivity by recommending improvements to the work flow processes and organizational structure.
Contribute to team effort by accomplishing related results as determined by management.
Attend meetings as necessary either internally or with the HMOs