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Medical Claims Auditor

Requisition #

20373

Location

San Francisco Bay Area

Employment Type

Full-Time

Position Summary

Responsible for the review and processing of regular claims using established claim standards and departmental policies and procedures ensuring that the work is performed accurately and delivered to meet set objectives.

Essential Duties & Responsibilities

• Accurately evaluates and adjudicates complex claims in a timely manner and according to set standards. Regular claims include but not limited to professional claims, Lab, DME, ambulance, as well as outpatient facility UB claims.
• Able to review and match authorization for the service.
• Assists in optimizing work flows, troubleshooting and problem solving to claims.
• Develop and maintains any/all necessary documentation for claims adjudication
• Identifies and resolves provider billing issues, including provider/vendor communication in writing.
• Ensures accurate interpretation of government laws, rules and any regulations, as well as internal organization guidelines.
• Research, accesses and utilizes on-line reference for claim issues and resolution.
• Assists with completion of claims audits conducted on TPA.
• Accepts and performs other duties as assigned, including frequent special projects.

Qualifications

• Good English (verbal and writing) is required.
• College preferred.
• Insurance claims and Healthcare administration background strongly preferred.
• Strong computer skills required. Any programming / database skill is highly preferred.
• Advanced MS Excel skills including pivots, vlookup, conditional formatting
• MS Access skills are highly preferred
• Very strong data analytical skills
• Very strong claims data analysis
• Strong claims reimbursement knowledge
• Claims auditing experience
• Strong mathematics skills

Physical requirements

  • Able to lift up to 30 pounds
  • Use proper body mechanics when handling equipment
  • Standing, walking and moving 50% of the day.

Compliance requirements

Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.

Base Pay Scale

Starting at $24.28/hour – $36.39/hour

The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.