Claim Auditor I

Cook Children's Health Care System; Fort Worth (TX); On-site; USD 52,000 - 76,000; Full time

Job summary

Cook Children's Health Care System is seeking a Claim Auditor I to audit behavioral and medical claims and ensure quality metrics for Texas Medicaid and CHIP programs. The role includes monthly sampling of claims from routine to moderate complexity, including paper and electronic submissions, with verification of coding and system configuration.

The position requires 5+ years of claims/audit experience or an Associates degree, strong organizational and communication skills, and proficiency in

Qualifications

• Associates degree or a minimum of 5 years of claims/audit experience.
• 7–10 years of medical claims processing experience including claim adjudication, coordination of benefit plans, medical terminology and coding.
• Strong organizational, problem solving and decision-making skills.
• Advanced knowledge of claim adjudication and benefit plan applications for Medicaid and CHIP programs.
• Proficiency with Microsoft Office including Word, Excel and Access.
• Excellent customer service skills with ability to explain complicated benefit issues to staff and providers.

Responsibilities

• Audit behavioral and medical claims and ensure quality metrics on Texas Medicaid and CHIP programs.
• Audit a monthly set of claims sampling for routine to moderate complexity (paper and electronic submissions).
• Ensure claim payment integrity aligns with regulatory standards, timelines, and contracts; document findings in structured reports.
• Pre-audit high-dollar claims to ensure payment accuracy before release.
• Communicate audit results to the Reimbursement and Analysis Manager within required timelines.

Skills

Organizational skills

Problem solving

Decision making

Communication skills

Customer service

Education

Associates degree

Tools

Word

Excel

Access

Microsoft Office

Job description

Location: Calmont Operations Building

Department: Reimbursement Analysis

Shift: First Shift (United States of America)

Standard Weekly Hours: 40

Summary: The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle.

Summary: The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims. The Claim auditor is also responsible for pre-auditing high dollar claims to ensure claim payment is accurate before releasing the claim for payment. The Claim Auditor I is also responsible for communicating audit results to the Reimbursement and Analysis Manager in a structured report format within required timelines. Results of the audits are to be communicated to the Claims Department. The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle.

Education

• Associates degree required or a minimum of 5 years of claims/audit experience which includes experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment preferred.

• 7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding.

• Must have strong organizational skills, problem solving and decision-making skills.

• Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs.

• Microsoft Office skills including Word, Excel and Access.

• Excellent customer service skills with ability to explain complicated benefit issues to staff and providers.

About Us

Cook Children's is an equal opportunity employer. As such, Cook Children's offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.