Hospital Claims Auditor

Summary:

A Hospital Claims Auditor is responsible for the overall quality of claims processes as well as compliance, in accordance with outside regulations and the contractual obligations of the Health Plans and/or Hospital Clients. Research, reviews and contacts provider services for problem claims and issues, as needed. Suggests process improvements to management and is a resource of information to all staff. The Claims auditor also performs special projects and helps department manager and director as needed. They review and audit the Examiners’ adjudicated claims for accuracy and providing feedback.

Duties and Responsibilities:

· Audit daily processed claims through random selection as outlined by organizational Policies and Procedures. Utilize appropriate system-generated reports applicable to specialty claims.

· Conduct Claims Examiner training as required. Document training materials and attendees.

· Conduct in-depth research of contract issues, system-related problems, claims processing Policies and Procedures, etc., to confirm cause of trends. Recommend actions/resolutions to Senior Management.

· Work with other organizational departments

· Assist in the development of Claims Department Policies and Procedures.

· Provide backup for other auditors/trainers within the Department.

· Perform other tasks as assigned by Senior Management.

· Promote a spirit of cooperation and understanding among all personnel.

· Attend organizational meetings as required

· Adhere to organizational Policies and Procedures.

· Adhere to MedPOINT Management’s core value: Accountability, Community, Celebration, Integrity, Innovation & Collaboration

Minimum Job Requirements:

· High School Diploma required.

· Three years of experience in a managed care claims adjudication setting e.g., HMO/MSO, required.

· Expertise in coding structure, ICD-10, CPT-4 and Revenue Codes, required.

· Definitive understanding of provider and health plan contracting, delineation of risk, medical terminology and standard industry reimbursement methodologies required.

Knowledge, Skills and Abilities Required:

· Strong organizational, analytical and oral/ written communication (English) skills required.

· Proficiency in PC application skills, e.g., word processing, spreadsheets, preferred

· Experience in training development and presentation preferred

· Must be able to follow directions and also perform independently according to departmental standards.