Claims Audit Coordinator

HealthCare Partners, IPA and HealthCare Partners, MSO together comprise our health care delivery system providing enhanced quality care to our members, providers and health plan partners. Active since 1996, HealthCare Partners (HCP) is the largest physician-owned and led IPA in the Northeast, serving the five boroughs and Long Island. Our network includes over 6,000 primary care physicians and specialists delivering services to our 125,000 members enrolled in Commercial, Medicare and Medicaid products. Our MSO employs 200 skilled professionals dedicated to ensuring members have access to the highest quality of care while efficiently utilizing healthcare resources.

HCP’s vision is to be recognized by members, providers and payers as the organization that delivers unsurpassed excellence in healthcare to the people of New York and their communities. We pride ourselves on selecting the most qualified candidates who reflect HCP’s mission of serving our members by facilitating the delivery of quality care. Interested in joining our successful Garden City Team? We are currently seeking a Claims Audit Coordinator in our Garden City Office!

Position Summary: The Claims Audit Coordinator is responsible for auditing claims processing activities to ensure compliance with HCP guidelines, specifically focusing on payment and procedural accuracy. This role plays a critical part in safeguarding the accuracy of completed claims before payment is issued, identifying trends, and recommending process improvements.

Essential Position Functions/Responsibilities

• Perform thorough audits on all processed claims, including adjustments, to ensure compliance with HCP guidelines.
• Identify and analyze both positive and negative trends through ongoing auditing and internal reporting, proactively recommending corrective actions or process improvements as needed.
• Generate, review, and analyze data processing reports, making necessary corrections or adjustments to claims data.
• Investigate and resolve any discrepancies or issues arising from audit results, ensuring timely follow-up and resolution.
• Assist in the training and development of internal audit staff, sharing expertise and best practices to enhance team performance.
• Maintain and update the audit database to support departmental evaluations, ensuring accurate records are available for internal and external use.
• Collaborate with other departments to assist in the preparation of external audits, ensuring compliance with regulatory and organizational standards.
• Price pharmaceutical drugs using an external database, ensuring claims reflect accurate and up-to-date pricing.
• Perform other duties as assigned to support departmental and organizational objectives.
  
  

Qualification Requirements

Skills, Knowledge, Abilities

• Strong working knowledge of CPT, HCPCS, Revenue, and ICD coding standards.
• Extensive experience with both professional and hospital claims adjudication processes.
• In-depth knowledge of CMS claims processing guidelines and Correct Coding Initiative (CCI) standards.
• Proficient in the use of Microsoft Windows applications, particularly Excel and other data management tools.
• Strong analytical skills with the ability to detect patterns and anomalies in claims data.
• Ability to manage multiple tasks effectively in a fast-paced, dynamic work environment.
• Detail-oriented with a commitment to ensuring high levels of claims processing accuracy.
• Strong problem-solving skills, with the ability to identify solutions to complex claims issues.
• Excellent communication skills for cross-departmental collaboration and training.
  
  

Training/Education

• High School Diploma or equivalent required.
• Some college coursework preferred, with a focus on health administration, business, or a related field.
  
  

Experience

• Minimum of 3 years of experience in claims processing, preferably within a managed care or health plan setting.
• Experience in auditing claims or working in a quality assurance capacity within a healthcare environment is highly desirable.
  
  

Base Compensation; $50,000 - $60,000 annually ($24-$28 per hour)

Bonus Incentive: Up to 5% of base salary

HealthCare Partners, MSO provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, HealthCare Partners, MSO complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Department: Claims

This is a non-management position

This is a full time position