Claims Auditor

Alhambra, CA 91801

Employment Type: Direct Job Category: Claims Job Number: 46241

Our client, an established managed care organization, is seeking a qualified Medical Claims Auditor to perform routine and complex audit of claims and identify inaccurate claims adjudication. The Claims Auditor will summarize findings and recommendations in reports for feedback and correction to the claims examiners and management. Ideal candidate has experience in ensuring claims adjudication in accordance to State, Federal regulations in a managed care or health plan setting.

Responsibilities:

  • Maintain current knowledge of all ICD-9, IDC-10, CPT, and HCPC codes.
  • Proficient with Federal and State requirements in claims processing.
  • Knowledge of general billing for both health care providers and institutions.
  • Generate and utilize reports to perform pre and post audit for all examiners, at all level and to capture deficiencies in processed claims prior to check run.
  • Must be able to work with Claims Examiners, give direction and answer claims related questions to improve overall quality of the department and individual examiners
  • Identify any incorrect billing, coding, NCCI edits, duplicate payments, and incorrect payment adjudication.
  • Process appeals and/or Provider Dispute Resolution
  • Resolve any grievances and complaints received through Customer Services
  • Identify any overpayment underpayment in a review and or history search and Collaborate with Recovery Analyst on any type of overpayment on a claim
  • Recognize claim correspondences from multiple IPAs.
  • Support the Claims Department as business needs require.
  • Maintains the strictest confidentiality at all times.

Qualifications:

  • Knowledge of MS Word, Excel and basic medical terminology
  • 3+ years experience as a Medical Claims Auditor
  • EZ-CAP knowledge preferred
  • Bachelor's degree preferred

Benefits:

  • Full Medical/Dental Insurance 100% Employee-paid Premium Coverage
  • Generous PTO, Paid Sick Leave, Holiday Pay
  • Opportunity to create and foster a positive working environment in a team-oriented setting
  • Career advancement opportunities with an established, growing healthcare organization
  • Full-time, permanent position with stability with competitive starting pay and excellent benefits package

This is a full-time, permanent position, onsite in an office-setting with a growing managed care organization. Please submit your resume to learn more about our client!

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