Claims Auditor

Centers Plan for Healthy Living; New York (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

Centers Plan for Healthy Living (CPHL) seeks an experienced claims auditor to ensure Medicaid/Medicare claim processing aligns with federal, state, and CPHL guidelines.

You will conduct monthly audits, monitor coding accuracy, prepare management summaries, and identify opportunities to improve workflows, data quality, and compliance in a fast-paced health-plan environment.

Qualifications

• Requires BA/BS in a financial field or equivalent healthcare experience.
• 2+ years of claim processing experience with Medicaid/Medicare Health Plan.
• Proficiency with MS applications (Word, Excel, Outlook).

Responsibilities

• Conducts monthly audits of CPHL claims per guidelines and regulatory requirements.
• Follow defined audit processes and stay updated on departmental changes.
• Ensure correct use of current codes and accurate documentation.
• Prepare management summaries of quality review results with trend analysis.
• Analyze audit results to suggest system or process improvements for better claim accuracy.

Skills

Analytical skills

Verbal communication

Written communication

Detail oriented

Multi-tasking

Education

BA/BS in financial field or equivalent healthcare experience

Tools

MS Word

MS Excel

MS Outlook

Job description

Individualized professional and personal growth is a primary focus at CPHL. With various teams to match the unique strengths of each individual, tiered roles to support the advancement, and with opportunities for cross-training and education, CPHL is the place for a fulfilling long-term career.

JOB SUMMARY:

Responsible for the auditing functions of Centers Plan for Healthy Living (CPHL) claims. Collaborates with other Health plan departments and Management to ensure claims are processed in accordance with Federal, State and CPHL established guidelines and/or policies and procedures. Provides feedback or suggestions to enhance current processes and/or systems; works under general supervision.

PRIMARY RESPONSIBILITIES:

• Conducts monthly audits of CPHL claims utilizing CPHL guidelines, policies and procedures or any other regulatory requirements.
• Follow defined audit processes and keep up to date with departmental changes in conducting quality reviews.
• Ensure the consistent use of current codes, correct information, documentation and departmental procedures by monitoring their use and identifying any deficiencies.
• Prepare summaries for management of quality review results, including basic analysis of identified trends.
• Analyzes audit results to recommend system or procedural changes to increase claim accuracy and/or identify opportunities for workflow enhancements.
• Evaluates Prospective Payment System (PPS) (e.g. APC, DRG, etc.) grouping and pricing information.
• Meets individual and departmental standards in regards to quality and productivity.
• Strong organizational, analytical and writing skills.
• Excellent verbal and communication skills.
• Maintain good working relationships within and outside of the department.
• Provides expertise and assistance relative to provider billing and payment guidelines consistent with CPHL policies and procedures and State or CMS guidelines.
• Performs other duties and special projects as assigned and directed.

EDUCATION AND EXPERIENCE:

Education

Required: BA/BS degree in a financial field or equivalent healthcare experience

Type of Experience

Required: 2+ years of claim processing experience with a Medicaid/Medicare Health Plan.

Preferred: Experience in health insurance product environment.

Specific Technical Skills

Required: Proficiency with MS applications, including but not limited to Word, Excel, Outlook

Certifications/Licensure:

Required: n/a

Knowledge and Skills:

• Effective presentation skills
• Excellent verbal and written communication skills
• Must be able to participate in meetings with all levels of management within the organization
• Detail oriented, excellent follow up
• Ability to multi-task in a fast paced environment
• Must be service oriented, quick learner, team player
• Appreciation of cultural diversity and sensitivity toward target population

SCOPE INFORMATION

# Direct Reports: n/a

PHYSICAL REQUIREMENTS

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be construed as an exhaustive list of all responsibilities, duties and skills required.