Claims Quality Auditor

HealthCare Resolution Services • Columbia, MD

203d • Remote

About The Position

The position involves auditing a portion of the combined financially stratified/attribute claim sample of medical and dental claims processed by medical care administrators. The audits will be conducted virtually with each administrator during a specified audit period, which for audits performed in 2024 will review claims processed from January 1, 2023, through December 31, 2023. The primary focus of the audits is to ensure compliance with eligibility, network participation, utilization review approvals, and correct application of benefit plan features.

Requirements

• Bachelor's degree in accounting, finance, or a related field such as health information management.
• At least three years of experience as a claims auditor or in a similar role in the health care industry.

Responsibilities

• Review and validate claimant eligibility for benefits on the date(s) of service based on administrator's eligibility files.
• Determine provider's network participation based on the date of service.
• Review claims requiring utilization review approval to ensure compliance with decisions.
• Ensure deductibles, coinsurance, and other cost-sharing features are correctly applied.
• Verify correct entry of claim data into the claim system, whether keyed or scanned.
• Check for other coverage available to the claimant and ensure correct payment coordination.
• Apply reasonable and customary or provider discount features correctly, including unbundling for physician services.
• Ensure appropriate edits are made to prevent duplicate payments.
• Confirm that billed and paid procedures are covered by the plan and not fraudulent.
• Verify the correctness of mathematics and computations related to claims.
• Ensure pre-authorization limits are applied appropriately.
• Check that paper claim forms are completed and signed correctly.
• Ensure adherence to internal policies and procedures during claim processing.
• Apply appropriate approvals to high dollar claims pre- and post-payment.
• Include sufficient documentation in the file to support claim adjudication.

What This Job Offers

• Career Level: Mid Level
• Industry: Administrative and Support Services
• Education Level: Bachelor's degree
• Number of Employees: 251-500 employees