Claims Auditor

Job Description: Claims Auditor will be responsible for auditing claims processed by Claims Examiners. Responsibilities include, but not limited to: Maintain up-to-date knowledge of procedures for all ICD-10, CPT, HCPC codes including: Contractual agreement rates Health Plan procedures Medicare and Medi-cal reimbursement Claims processing guidelines Evaluate claims based on DMHC and DHS regulations Respond and resolve providers’ and health plans’ inquires in a timely manner Check for adjudication errors and present them to respective Examiner Present recommendations for improvements for Examiners Identify escalating issues to appropriate team(s) and management Monitor aging claims with reports to maintain timeliness Maintain quality and productivity standards Maintain a minimum audit-accuracy rate Participate in special projects Collect claim sample data to perform audits Reports and works closely with Claims Manager Qualifications: Bachelor’s degree in related field or AA degree with related experience Must have at least 5 years of applicable healthcare claims adjudication experience within a managed care industry Must be familiar with ICD-10, HCPCS, CPT coding, APC, ASC, and DRG pricing. Must be familiar with facility (UB-04) and professional (CMS-1500) claim billing practices. Must have good written and communication skills. Must be able to follow guidelines, multi-task, and work comfortably within a team-oriented environment. Computer literacy required, including proficient use of Microsoft Word, Excel, Outlook, and EZ-CAP. EZ-CAP 6X is a plus. Typing skills of a least 40 wpm.