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Claims Auditor

Company: ApolloMed
Location: Monterey Park
Posted on: June 15, 2022

Job Description:

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 guidelines.KEY RESPONSIBILITIES:

  • 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 agreements
    • 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 adjudication errors
    • Document each individual review process, justification and conclusion
    • 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 management team
      • Support the Claims Department as business needs require.
      • Proficient in and performs the application of "Coordination of Benefits."
      • 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 claim.
      • Recognize claim correspondences from multiple IPAs.
      • Recognize the difference between Shared Risk and Full Risk claims.
      • Maintain required levels of production and quality standards as established by management.
      • Attendance at employer worksite is an essential job requirement.
      • Work assigned claim project to completion
      • Contribute to team effort by accomplishing related results as needed.
        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 essential functions.
        • Knowledge of MS Word, Excel and basic medical terminology is required.
        • 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 manage time
        • Position may require unscheduled overtime, week-end work
        • Ability to understand work with proprietary software applications.
        • Organizational ability and ability to exercise good judgment.
        • 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 delivery system.
        • 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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