Claim Auditor I

Cook Children's Health Plan; Fort Worth, Northern (TX, KY); Hybrid; USD 45,000 - 65,000; Full time

Job summary

Cook Children’s Health Plan is seeking a Claim Auditor I to audit behavioral and medical claims for Texas Medicaid and CHIP, ensuring compliance with regulatory standards. The role includes post-claims reviews, monthly sampling, and pre-audit of high-dollar claims along with reporting to the Reimbursement and Analysis Manager.

The ideal candidate has an Associate degree or 5+ years in claims/audit, 7–10 years of medical claims processing, and strong organizational and coding knowledge, with

Qualifications

• Associates degree required or a minimum of 5 years of claims/audit experience.
• 7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding.
• 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.

Responsibilities

• Audit behavioral and medical claims for Texas Medicaid and CHIP programs.
• Perform monthly sampling reviews of routine to moderate complexity.
• Ensure claims payment integrity aligns with standards, timelines and policies.
• Prepare structured audit reports for Reimbursement and Analysis Manager.
• Communicate audit results to the Claims Department.

Skills

Organizational

Problem-solving

Decision-making

Education

Associate degree

5+ years claims/audit experience

Tools

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.

Responsibilities

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. Promise, a strong word with deep meaning that everyone understands - especially kids. This is the foundation of our organization and what drives us to blaze new trails in medical care, research, advanced technology, as well as programs and initiatives that benefit children who may not otherwise have access to quality health care. Every day our employees come to work with the intention of keeping our Promise. It's the guiding principle that helps our patients and their families get better and stay healthy. As a member of our Cook Children's team, you can be an important part of making that happen.