Director of Claims Audits
Job not on LinkedIn
November 15
📋 Description
• Auditing institutional and/or professional claims according to established policies and procedures. • Institutional Claims Report Review • Institutional full medical record review with no DRG change • Institutional full medical record review with DRG change and letter of explanation • Professional Claims Report • Professional Claims Review with Records • Symkey Review and Support
🎯 Requirements
• 10+ years or more experience in processing HMO claims in a managed care environment. • Proficient in Medical Record Review as it pertains to ICD10 coding. • Proficient in rate application for outpatient PPS & Inpatient DRG facility, ASC, APC, Interim Rate Payment methods to applicable lines of business. (Medicare, Commercial, Medi-Cal). • Familiar with all regulatory requirements including CMS, DMHC and DHS. • Proficient with all Federal and state requirements in claim processing. • Knowledge of medical terminology and coding. • Recognize the difference between Shared Risk and Full Risk claims. • Proficient in applying Division of Financial Responsibility. • Knowledgeable in applying Health Plan Benefit Matrices. • Proficient understanding of AB1324. • Proficient understanding of AB1455 Claims Settlement Practice & Dispute and Resolution regulations. • Excellent communication skills including reports, correspondence, and verbal communications. • Demonstrated proficiency with Microsoft Word and Excel.
🏖️ Benefits
• 100% employer paid medical, vision, dental, and life coverage • Paid holiday • Sick time • Vacation time • 401k plan • Additional employee paid coverage options available
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