Claims Auditor
Job not on LinkedIn
November 6
📋 Description
• Conduct retrospective and concurrent audits of claims to verify accuracy of payment, coding, and rate application. • Review claims for proper application of Division of Financial Responsibility (DOFR), benefit matrix interpretation, and regulatory compliance. • Validate application of DRG, APC, ASC, and PPS payment methodologies. • Identify trends and root causes of claim processing errors and recommend corrective actions. • Assist with preparation of audit findings and reports for management review. • Support internal quality control by providing feedback and training recommendations. • Collaborate with the Claims Audit Director to ensure consistent audit methodology and reporting standards. • Maintain knowledge of current CMS, DMHC, and DHS regulations as well as company policies related to claims adjudication. • Participate in special projects, focused audits, or process improvement initiatives as assigned.
🎯 Requirements
• Minimum 5–7 years of experience in HMO or managed care claims processing. • Strong understanding of ICD-10, CPT, and HCPCS coding principles. • Knowledge of payment methodologies including DRG, APC, ASC, PPS, and other applicable rate structures. • Familiarity with regulatory requirements and claims settlement practices. • Proficient in interpreting benefit matrices and DOFR. • Strong analytical, problem-solving, and documentation skills. • Proficiency in Microsoft Excel and Word. • Excellent written and verbal communication skills.
🏖️ Benefits
• 100% employer paid medical, vision, dental, and life coverage for employees. • Paid holiday, sick time, and vacation time. • 401k plan. • Additional employee paid coverage options available.
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