OVERALL JOB PURPOSE

The main function is to audit delegated and non-delegated professional, and facility claims for accurate processing per contract, health plan guidelines, State and Federal regulations within payment compliance time limits. This position will also be responsible for analyzing data, presenting data, and processing claims, if applicable.

MINIMUM JOB QUALIFICATIONS AND REQUIREMENTS

• Education:
• High school diploma or GED. Some college preferred.
• Experience:
• Claim Audit Analyst must have significant experience (8 years minimum) in the Medical Claims payment industry specializing in professional and facility claims payment and processing provider appeals.
• Knowledge, Skills and Abilities:
• Must have a strong understanding of any local, state and federal rules regarding the adjudication of medical benefits.
• Personal computer with main frame emulation, claims management software, word processing and management software, 10-key adding machine, Imaging retrieval software, fax machine, copy machine, basic office aids.
• Working knowledge of HMO operations, claims delegation compliance, and contract interpretation.
• Strong knowledge of CPT, HCPCS, ICD-10, DRG and APC coding and CMS Guidelines.
• Strong organizational and time management skills with the ability to prioritize individual workloads,
• Must have excellent analytical and “people skills”.
• Must be efficient in Microsoft Office Suite Products

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

• Responsible for quality and continuous improvement within the job scope.
• Responsible for all actions/responsibilities as described in company controlled documentation for this position.
• Contributes to and supports the corporation’s quality initiatives by planning, communicating, and encouraging team and individual contributions toward the corporation’s quality improvement efforts.
• Conduct pre and post payment audit of professional and institutional claims for accurate payment per contract, health plan, state and federal requirements.
• Process and resolve provider claim appeals within contract, health plan, state and federal compliance time limits.
• Answer questions for customer service regarding appeal decisions.
• Perform adjustment adjudication for professional claims under-paid, over-paid, or in some other fashion incorrectly adjudicated.
• Must be able to take data and analyze, and render analysis based on the data, and give recommendations on the analysis

OTHER JOB DUTIES AND RESPONSIBILITIES

• Performs other work-related duties and responsibilities as directed, assigned or requested.

WORKING CONDITIONS

• Working conditions are normal for an office environment.

PHYSICAL REQUIREMENTS

• The physical demands are those that must be met to successfully perform the essential functions of the job.

Summary

• This job description reflects the general duties of the position and is not intended, and should not be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job.