Managed Care Claims Auditor
About the position Responsibilities • Perform concurrent and retrospective review of paper & electronic claims processed and office services fulfillment team Optical Character Recognition (OCR), clearinghouse and mail interface vendor activities' performance at all levels. • Review routine random sampling audit of examiner processed claim(s) for accuracy and provides feedback to the examiner. • Review support team workflows to ensure regulatory timeliness, distribution and accuracy guidelines are met. • Report metric volume, procedural and financial accuracy on a recurring schedule to claim management. • Identify root cause of system and/or examiner errors, report to claim leadership for appropriate corrective action. • Partner with claim management on performance management recommendation. • Weekly review of high-dollar claims. • Review and analyze audit data, including trend results with recommendation of process changes, refresher training and system enhancements to improve systemic examiner and system quality/performance. • Maintain working knowledge of department policies and procedures for use in standard audit workflows in claim & support departments. • Perform focus audit as necessary. • Perform other duties as assigned, including but limited to, processing of claims, PDR, adjustments, overpayments, etc. Requirements • Subject Matter Expert (SME) in medical claims processing at health plan payor, Managed Services Organization (MSO), Health Maintenance Organization (HMO) and/or Independent Practice Association (IPA) organization. • Hands-on knowledge and functional understanding of medical claims billing, processing, terminology, diagnosis and procedures. • Working knowledge of Commercial, Medicare and HMO lines of business processes. • Ability to effectively review, interpret and apply Division of Financial Responsibility (DOFR) requirements. • Personal laptop and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, PowerPoint. • Technical proficiency in database and worksheet program applications. • Identify ICD-10, CPT-4, HCPCS, Revenue Codes, UB-04 and CMS-1500 forms. • Work cooperatively and interact with auditors, examiners, support team and management positively. • Adapt to changes in requirements/priorities on a daily basis. • Produce logs and reports as required. • Effectively communicate orally and in writing. • Analyze and evaluate information in an accurate manner. • Interpret policies & procedures. • Work independently using sound judgement in ambiguous and defined concepts. • Exercise outstanding time management capabilities. • Accept accountability of all tasks and results. Nice-to-haves • Prior medical claim auditing experience preferred. Benefits • Comprehensive medical coverage that covers many common services at no cost or for a low copay. • Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more. • Free counseling services and resources for emotional, physical and financial wellbeing. • 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service). • Employee Stock Purchase Plan with 10% off HCA Healthcare stock. • Family support through fertility and family building benefits with Progyny and adoption assistance. • Referral services for child, elder and pet care, home and auto repair, event planning and more. • Consumer discounts through Abenity and Consumer Discounts. • Retirement readiness, rollover assistance services and preferred banking partnerships. • Education assistance (tuition, student loan, certification support, dependent scholarships). • Colleague recognition program. • Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence). • Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income. Apply tot his job