Claims Quality Auditor

University of California System • Los Angeles, CA

75d • $31 - $62 • Hybrid

About The Position

Take on a key role within a world-class, award-winning health system. Ensure the efficient delivery of award-winning patient care. Take your career in an exciting new direction. You can do all this and more at UCLA Health. You will be responsible for monthly random and focus audits of all claim processing activities to identify inaccurate claims adjudication. This will involve reviewing UB04 and CMS 1500 healthcare claims and adjustments for accuracy, and appropriate application claims adjudication, including CMS regulations, Department of Financial Responsibility provisions, Medicare Advantage Plan requirements, policies and procedures, and internal operations guidelines. You will also compile and maintain statistical data and ensure compliance with production and quality standards in accordance with department policy.

Requirements

• Bachelor's degree and/or equivalent experience.
• Five or more years of medical claims payment experience in Medicare Advantage or combination of.
• Expertise in industry-standard claims adjudication policies, procedures, and processes.
• Knowledge of fee schedule and pricing methodologies for outpatient/inpatient institutional, ancillary, professional claims, and Medicare fee schedules.
• Understanding of CPT, HCPCS, ICD-10, ASA, Revenue Codes.
• Experience researching and resolving provider dispute resolutions, adjustments, appeals, and reopen guidelines.
• Understanding of Claim Adjustment Reasons and Remittance Advice Remark codes.
• Knowledge of medical terminology.
• Ability to accurately key between 6,000 and 8,000 keystrokes or type 40 - 50 WPM.
• Strong analytical, mathematical, organizational, and problem-solving skills.
• Computer proficiency with Microsoft Word and Excel.
• Knowledge of claims adjudication systems (e.g., EPIC-Tapestry, QNXT, IDX Facets).
• Willingness to learn new technologies, practices, and procedures.

Responsibilities

• Conduct monthly random and focus audits of all claim processing activities.
• Review UB04 and CMS 1500 healthcare claims and adjustments for accuracy.
• Ensure appropriate application of claims adjudication including CMS regulations.
• Compile and maintain statistical data.
• Ensure compliance with production and quality standards.

What This Job Offers

• Industry: Educational Services
• Education Level: Bachelor's degree