Description:

This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHS. This position includes the responsibility for routine hospital and professional audits, complex audits on individual or random, training and focused claims to identify exceptions to established claims adjudication requirements for claims processing, payment and procedural accuracy. In addition, this position is responsible to assist with eligibility identify (e.g. COB, ESRD) and Letters of Agreements as required. To maintain in strict confidence, all member, provider and Health Plan information to which Claims Auditing Specialist has access.

Skills:

ez cap, claims examiner, claims coordinator hippa, hmo, ppo

Top Skills Details:

ez cap, claims examiner, claims coordinator hippa, hmo, ppo

Additional Skills & Qualifications:

1. Performs routine and complex audits on individual, random, trainee and focused claims to identify exceptions to established claims adjudication requirements for both Pre-EOB and post payment. 2. Perform 1st level audit based on reports and run Virtual Examiner Reports prior to each check run. 3. Researches claim processing problems and errors to determine their origin and appropriate resolution. 4. Researches member activity to identify Coordination of Benefits, Third Party Liability, Out-of-Area and Workers’ Compensation as identified through member admissions, authorization process or claims activity 5. Notify management immediately if any report processing deadlines cannot be met. 6. Identify, proactively through auditing and internal reporting, negative and positive trends and initiate recommendations for change 7. Analyze data processing reports and make necessary corrections or adjustments 8. Assist with training of claims adjudication staff as needed 9. Assist manager with follow-up on any problems or questions related to the audit results 10. Other duties as assigned

Experience Level:

Entry Level

About TEKsystems:

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.