Location: Monterey Park
Posted on: June 15, 2022
SUMMARYClaims Auditor I is responsible for performing routine
and complex audit of claims payment for pre- and post- check run.
The Claims Auditor I will summarize findings and provide
recommendations to the reporting Supervisor and Manager. The
position is expected to clearly understand the products &
healthcare benefit services offered to the capitated members that
we manage, including the division of financial responsibility, as
well as the associated limits and regulatory rules and
- Proficient in, and knows how to use and apply Health Plan
Benefit Matrices and DOFR (Division Of Financial Responsibility).
- Facilitate the correction of claim adjudication errors.
- Test and audit new releases of Medicare and Medi-Cal Fee
Schedules, provider payment pricing methodologies based on contract
- Understand the types of provider contracting arrangements
and/or benefits administration data elements that need to be
configured in the appropriate applications to support the accurate
& timely payment of claims
- Maintain knowledge of all ICD-9, CPT, HCPC codes, general
billing procedures for health care providers and institutions, as
well as Medicare and Medi-Cal reimbursement guidelines
- Test and audit claims payments for accuracy against contract
information loaded into EZCAP
- Generate and utilize audit reports for identifying claim
- Document each individual review process, justification and
- Maintains detailed knowledge & understanding of EZCAP rules
relative to claims payment
- Track and analyze claims adjudication errors
- Flexibility to accept special and/or ad hoc projects
- Adhere to corporate standards for performance metrics, data
integrity, and reporting format to ensure high quality, meaningful
output and the strictest confidentiality at all times.
- Perform other duties as necessary or assigned by NMM's
- Support the Claims Department as business needs require.
- Proficient in and performs the application of "Coordination of
- Comply with claims timeliness guidelines: Commercial 45 working
days; Medi-Cal 30 calendar days; Medicare non-contracted 30
calendar days and Medicare contracted 60 calendar days. Identify
any overpayment underpayment in a review and or history search and
Collaborate with Recovery Analyst on any type of overpayment on a
- Recognize claim correspondences from multiple IPAs.
- Recognize the difference between Shared Risk and Full Risk
- Maintain required levels of production and quality standards as
established by management.
- Attendance at employer worksite is an essential job
- Work assigned claim project to completion
- Contribute to team effort by accomplishing related results as
QUALIFICATIONS:To perform this job successfully, this individual
must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge,
skill, and/or ability required. Reasonable accommodations may be
made to enable individuals with disabilities to perform the
- Knowledge of MS Word, Excel and basic medical terminology is
- Typing speed 50+ WPM and knowledge of 10 key desired.
- Ability to multi-task and meet deadlines.
- Strong organization skills; ability to multitask and properly
- Position may require unscheduled overtime, week-end work
- Ability to understand work with proprietary software
- Organizational ability and ability to exercise good
- Work independently as part of a team.
- At least 2 years complex claims processing and/or auditing
experience in the health insurance industry or medical health care
- At least 2 year of experience in managed health care
environment related to claims processing/audit
EDUCATION and/or EXPERIENCEBachelor's degree (B. A.) from four-year
college or universityEZ-CAP knowledge; or equivalent combination of
education and experience.#LPIND
Keywords: ApolloMed, Monterey Park , Claims Auditor, Accounting, Auditing , Monterey Park, California
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