Claims Auditor
Company: AltaMed Health Services Corporation
Location: Montebello
Posted on: January 27, 2023
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Job Description:
Overview:
The Claims Auditor will be responsible for the accurate review and
auditing of claims that are adjudicated by the system and the
Claims Examiners. The auditor will suggest process improvements to
management and act as a resource of information to all staff. The
Claims Auditor will identify overpayments and coordinate with the
Claims Recovery Unit.
Responsibilities:
Audit claims as it relates to the appropriate Federal and State
regulations based on the member's Line of Business.Read and
interpret DOFRs as it relates to the claim in order to ensure that
group is financially at risk for payment.Read and interpret
provider contracts to ensure payment accuracy.Read and interpret
Medi-Cal and Medicare Fee Schedules.Utilize auditing tools to
identify and determine accuracy of claims payments (prospectively
and retrospectively).Coordinate with internal departments for any
issues relating to provider, fee schedule, eligibility,
authorization, or system issues.Complete appropriate documentation
for tracking/trending of data in order to identify system issues
and remediation.Provide regular feedback to the Claims Management
team concerning process improvement opportunities, or any training
opportunities relative to adequacy of file investigation/
development in advance of the recovery effort.Coordinate with the
Recovery Department for any identified overpayments.Ability to
establish and maintain positive and effective work relationships
with coworkers, clients, members, providers and customers.Other
duties as assigned.
Qualifications:
HS Diploma or GED3+ years of Claims Processing experienceMust be
knowledgeable of Medi-cal regulationsPreferred knowledge of
Medicare and Commercial rules and regulationsKnowledge of medical
terminologyMust have an understanding to read and interpret DOFRs
and Contracts.Managed Care conceptsMust have strong organizational
and mathematical skills.
Min:
USD $22.32/Hr.
Max:
USD $34.60/Hr.
Keywords: AltaMed Health Services Corporation, Montebello , Claims Auditor, Other , Montebello, California
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