Claims Auditor/Trainer
Claims Auditor/Trainer
JOB SUMMARY:
Perform routine and complex audits on claims to identify inaccurate claims adjudication. Will run and audit focused audit reports on a daily basis. Track, research, and document audit findings and determine origin and appropriate resolution. Pre-audit claims selected for health plan audits. Summarize findings and recommendations in reports for feedback to Claims Examiners and Management. Review claims audit results with Director of Claims and Claims Supervisor in order to improve claims processing accuracy. Ensures claims adjudication is in accordance with State, Federal and Health plan regulatory requirements as well as departmental guidelines. Provide initial claims processing training for Claims Representatives. Provides qualified data for incorporation into training programs, policies and procedures. Assist with functional testing on cross departmental projects.
MAJOR DUTIES AND RESPONSIBILITIES:
- Responsible for reviewing claims transaction audit reports, perform claims adjudication quality review to assure compliance with health plan audits. Complete daily, weekly and monthly audits. Perform daily review of pre and post-payment audit reports and daily review of all denied claims.
- Responsible for maintaining the Claims Policies and Procedures, to include updating and development of new documents, as needed.
- Develop and provide statistical data on individual employee errors and conduct analytical research to effectively resolve processing issues. Identify error trends for specific training needs for Claims staff. Support Claims Supervisor by identifying training needs.
- Responsible for performing initial training of Claims Representatives, utilizing established training guides, curriculum and materials. Provide training progress feedback to the Claims Supervisor.
- Perform pre-audit review of claims targeted for scheduled Health plan audits.
- Review claims operational reports to ensure compliance with State, Federal and Health plan regulatory requirements.
- Provides the primary quality review statistics in determining non-exempt employee claims adjudication quality performance.
- Exhibit a thorough understanding of industry standard claims processing guidelines.
- Provides technical assistance on special projects, utilizing ability to interpret claims policies, including analysis and functional testing support.
- Accepts and performs other duties as assigned with reasonable independence.
QUALIFICATIONS:
EDUCATION AND/OR TRAINING:
High school graduate, some college desired. Knowledge of and working experience with ICD-9, CPT and HCPC coding systems. Thorough knowledge of medical terminology, enrollment and membership activities and claim processing procedures/systems. Basic understanding of Microsoft Word and Excel applications.
SKILLS AND ABILITIES:
Ability to work independently, organize, and prioritize work assignments. Independent decision making skills and demonstrate initiative to resolve issues. Excellent oral and written communication skills, great organizational skills and ability to prioritize projects. Ability to exercise good judgment and handle a fast paced environment. Able to assess and coordinate departmental work flows effectively. Ability to process all types of medical claims and interpret authorizations, contracts and physician reimbursement methodologies. Ability to train using instructional materials.
EXPERIENCE:
Seven (7) years prior claims processing experience in an IPA or HMO related setting. Prior experience with training preferred.