Claims and Call Auditor (Call Center QC)

Premier Administrative Solutions; Clearwater (FL); On-site; USD 40,000 - 60,000; Full time

Job summary

An established industry player is looking for a Claims and Call Auditor to ensure the accuracy and compliance of processed medical insurance claims. This role involves auditing claims, analyzing customer service calls, and preparing detailed reports based on findings. The ideal candidate will have strong organizational and communication skills, along with knowledge of medical terminology and coding systems. Join a dynamic team where your contributions will help maintain high standards of quality and compliance in a supportive office environment. If you are detail-oriented and passionate about improving service quality, this opportunity is perfect for you.

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Life Insurance

Paid Time Off

Paid Holidays

Qualifications

• Prior auditing experience is preferred.
• Knowledge of medical terminology and coding systems is essential.
• Bilingual fluency in English/Spanish is a plus.

Responsibilities

• Perform random medical audits and ensure compliance with regulations.
• Analyze customer service calls for quality assurance.
• Prepare audit reports and communicate findings to leadership.

Skills

Auditing

Medical Terminology

Medical Coding Systems

Medicaid/Medicare Guidelines

Billing Rules and Regulations

Organizational Skills

Communication Skills

Detail Oriented

Bilingual (English/Spanish)

Education

High School Diploma

Tools

MS Word

PowerPoint

Excel

Outlook

Job description

Overview

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Claims and Call Auditor (Call Center QC) - Clearwater, FL

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SummaryThe Claims & Call Auditor audits processed medical insurance claims and customer service calls to ensure validity, accuracy, and compliance with appropriate policies, procedures, and regulations

• Health, Dental, Vision, and Life Insurance as well as Paid Time Off and Paid Holidays!

Location: Clearwater, FL [Highpoint, ICOT] - On-Site, In-Office Position

Hours: Monday - Friday, 8:00AM-5:00PM

Responsibilities

Essential Duties and Responsibilities:

• In accordance with company guidelines, performs random medical audits, target audits, re-audits, etc and audits for claims which are in excess of payment authority limits in assigned audit queues.
• Listen to and view all recorded customer service calls within the MPS call center.
• Ensures compliance with appropriate company policies, procedures, guidelines, and reporting requirements; Federal and state regulations; and timeliness of claims processing.
• Utilize Excel, prepares tracking and trending written audit reports based on findings and communicate audit findings with appropriate leadership, with accuracy, and work with the MPS Call Center Manager/Supervisor/Team Lead and analyze the data for training purposes.
• Identifies patterns, trends, and variances related to claims and calls and provides feedback to their Manager.
• Maintains up-to-date working knowledge on regulatory requirements associated with billing and claims processing, as well as HIPAA guidelines/established Encryption policies and procedures.
• Reviews Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) to determine proper category for benefit code determination.
• Create training materials via PowerPoint, and other multiple media platforms as determined by management.
• Participates in all aspects of the organization’s Compliance Program which may include assigning New Hire and Employee Annual Compliance training.

Other Responsibilities:

• Adheres to the policies and procedures of PFC Shared Services.
• Maintains strict confidentiality of client, company and personnel information.
• Demonstrates a strong commitment to the mission and values of the organization.
• Adheres to company attendance standards.
• Performs other duties as assigned.

Supervisory Responsibilities: None

Competencies:

• Strong organizational and interpersonal skills
• Excellent written and verbal communication skills
• Detail oriented
• Ability to multi-task and work independently

Qualifications

Qualifications:

• Prior auditing experience is preferred
• Knowledge of medical terminology
• Knowledge of medical coding systems
• Knowledge of Medicaid/Medicare Guidelines
• Knowledge of billing rules and regulations.
• Strong organizational and interpersonal skills
• Excellent written and verbal communication skills
• Detail oriented
• Ability to multi-task and work independently
• Bilingual fluency is a plus [English/Spanish]

Education and/or Experience:

• A high school diploma or equivalent is required
• Experience in medical customer service, quality assurance, or insurance training is preferred.

Certificates, Licenses, Registrations:

None

Computer Skills:

Proficiency using software programs such as MS Word, PowerPoint, Excel and Outlook

Environmental Factors/Physical Demands:

Work is performed in an office environment. While performing the duties of this job, the employee is regularly required to have the ability to maintain active customer and employee communication; access, input and retrieve information from the computer system; enter alpha-numeric data into a computerized system often while listening on the telephone. May be subject to repetitive motion such as typing, data entry and vision to monitor. May be subject to bending, reaching, kneeling, stooping and lifting up to thirty (30) pounds.

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Claims and Call Auditor (Call Center QC) - Clearwater, FL

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