Claims Specialist

APS Health Care PR

1d

About The Position

The Claims Specialist (Auditor) position is responsible for assuring compliance with Medicaid, Commercial claims payment regulation. This position contributes to the identification and recovery of improper payments through management of claims audit timelines, billing, coding and payment analysis.

Requirements

• Associate degree or four (2) years of experience in a directly related field
• Certification of compliance Medical Auditor, “CMA”
• Minimum three (3) years of claims processing with minimum two (2) years of claims auditing experience.
• Knowledgeable with insurance policy, Medicare regulations and general claim compliance
• Experience in CPT and ICD-10 coding and different pricing tools.
• Know several different coding systems, including Level 1 HCPCS and Level 2 HCPCS.

Responsibilities

• Conduct research and analysis utilizing claims and direct member reimbursement policies and procedures; the Center for Medicare and Medicaid Services (CMS) Manuals and pricing established for the Medicaid and commercial lines.
• Conduct claims and direct member reimbursements audits to evaluate compliance with Medicaid regulations and Commercial line.
• Able to work efficiently in teams and fluidly switch between team and self-directed work priorities.
• Reports possible instances of fraud and abuse, if found.
• Validation of the reimbursements worked by the Claims Department of the different products for the Medicaid and Commercial business lines.
• The Financial Recovery Claims Auditor will generate assessment reports monthly, quarterly, or as required.
• The Financial Recovery Claims Auditor will ensure: The charges listed on the invoice are correct. The services were paid according to the amount agreed upon in the service contract.
• Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.
• All other duties assigned by management.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees