POSITION SUMMARY:

These duties are split over four Auditor positions. Claims Auditors are responsible for the auditing of provider disputes, member denial letter requests, and daily prelag reports. Responsible for ensuring provider dispute and member denial letters are accurately handled. Responsible for notifying management of any compliance concerns with timeliness of claims payments. Reviewing and resolving HPIs and member OOP.

This position is primary focus on reviewing member out of pocket max notices and process corrections to member OOP as needed. Reviewing & processing member copay corrections. Position will also focus on check run reviews, including working all pre/post check run audit reports to ensure claims payments are accurate.

JOB DUTIES:

• Reviews provider disputes and letters for assigned region(s) on a daily basis for accuracy to ensure timeliness of acknowledgement and resolution. Log errors for use in annual performance review. Reports errors to Claims Manager monthly.
• Monitors pre-lag reports for assigned region(s) on a daily basis for compliance with health plan mandated turnaround times.
• Responsible for ensuring that Virtual Examiner edits are run each day and that the edits are accurately applied according to SCPMCS and Client guidelines.
• Reviews various check run reports.
• Reviews and processes Fax Backs.
• Works claim notes sent via email from BN team.
• Reviews Auditor pre-lag reports and send compliance issues to Lead Claim Auditor.
• Reviews and processes various daily/weekly reports for assigned IPA.
• Acts as back up for fellow Claims Auditor.

POSITION QUALIFICATIONS AND REQUIREMENTS

Experience/Specialized Skills:

• 3 years of experience in managed care claims processing.
• Knowledge of HCFA, Medi-Cal and HMO claims payment regulations.
• Claims auditing experience.
• Ability to communicate effectively, verbally and in written form.
• Ability to achieve collaborative problem solving among Claims and Eligibility Staff and with other SCPMCS departments and Health Plans.
• Competent in the use of computer programs, especially Microsoft Word and Excel.

Education/Course(s)/Training: High School Diploma required.

Licensure/Certification: N/A

Work Schedule:

• Monday – Thursday
• 10 Hour shift
• Non-clinical, office setting. This position has the potential to go remote upon successful completion of onsite training which is approximately anywhere from 90 – 120 days onsite.

View our company website to learn more about the company and career opportunities. You may apply through the company website or through Indeed.

www.scpmcs.org

SCPMCS is an Equal Opportunity Employer

Job Type: Full-time

Pay: $21.66 - $26.53 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Referral program
• Tuition reimbursement
• Vision insurance

Application Question(s):

• Do you currently reside in the San Diego, CA. area?
• How much knowledge of HCFA, Medi-Cal, and HMO claims payment regulations do you have?
• What is your salary expectation?

Education:

• High school or equivalent (Required)

Experience:

• Managed care: 3 years (Preferred)
• Microsoft Office: 2 years (Preferred)
• Medical Claims processing: 3 years (Preferred)
• Medical Claims auditing: 3 years (Preferred)

Location:

• San Diego, CA (Required)

Work Location: Remote