Senior Claims Auditor
$70,308–$80,000 year
HybridMonterey Park, California, United States
Job Summary
Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits, reviewing samples to ensure claims payments are accurate and required documentation is present. Respond to preliminary results by due dates, address root causes in corrective action plans, and remediate deficiencies while handling complex and urgent audit projects. Accurately document underpayments and overpayments into the audit database, run reports on error trends, and assist management with analyzing Claim error trends. Build collaborative relationships with department leads to enable timely problem resolution and identify training needs for the team. This role reports to the Director - Claims within the healthcare industry.
Required Qualifications
- A High School Diploma or Equivalent
- At least 2 years of experience as Medical Claims Auditor or 7 years previous experience examining Claims
- Solid understanding of the Department of Health Care Services (DHCS), Centers for Medicare & Medicaid Services (CMS) rules and regulations governing claims adjudication practices and procedures
- Detail knowledge and understanding of Industry pricing methodologies, such as Resources-Based Relative Value Scale (RBRVS), Medicare/Medi-Cal fee schedule, All Patient Refined Diagnosis Related Groups (AP-DRG), Ambulatory Payment Classifications (APC), etc
- Detail knowledge of Medi-Cal, Medicare, and Medicaid program guidelines
- Possess working knowledge of NCQA, DHS and HCFA standards
- Knowledge of medical terminology combined with detail knowledge and experience with CPT, HCPCS, DRG, REV, OPS, ASC, ICD10, CRVS, RBRVS, CMS, ICE for Health Plan, DMHC and DHS fee schedules and CMS Medicare regulatory agencies, COB and Third-Party Liability recovery
- Must have the ability to analyze and process all levels of claims accurately utilizing advanced level knowledge of CMS and DMHC Regulations
- Must possess the ability to effectively present information and respond to questions from managers, employees, customers
- Must possess advanced reasoning and problem-solving abilities and planning skills
- Ability to multi-task, prioritize and work in a fast-paced environment under minimal supervision
- Proficient in Excel to include the ability to create and revise Excel spreadsheets to provide accurate and clear reports
- Strong independent decision-making, influencing and analytical skills
- Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines
- Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis
Desired Qualifications
- Bachelor's degree preferred
Hiring someone like this?
Get your role in front of qualified candidates on Sorce.