Healthcare Claims Audit Specialist

Imperial Health Plan; Pasadena (CA); Vor Ort; USD 30.000 - 35.000; Vollzeit

Zusammenfassung

Imperial Health Plan is seeking a Claims Auditor to review and audit claims adjudicated by the system and examiners prior to check runs. You will verify compliance with CMS, Medi-Cal, and commercial guidelines, identify errors, and provide recommendations for process improvements.

The role requires 2+ years in complex claims processing or auditing, with EZ-CAP knowledge preferred. Strong analytic, communication, and multitasking abilities are essential in a fast-paced environment.

Qualifikationen

• Minimum 2 years of experience in complex claims processing and/or auditing in the health insurance industry.
• EZ-CAP knowledge strongly preferred.
• Proficiency in claims coding and forms (CCI, CMS-1500, UB-04, CPT, ICD-10, HCPCS).

Aufgaben

• Accurately apply Health Plan Benefit Matrices and DOFR during audits.
• Facilitate corrections of claim adjudication errors and recommend process improvements.
• Test and audit new releases of Medicare and Medi-Cal Fee Schedules, and provider payment methodologies based on contract agreements.
• Maintain a strong understanding of provider contracting arrangements and benefits administration to support accurate and timely claim payments.
• Stay current on ICD-10, CPT, HCPCS, Revenue Codes, DRG, and billing procedures for healthcare providers and facilities, as well as Medicare and Medi-Cal reimbursement guidelines.
• Test and audit claim payments for accuracy against contract data in E-CAP.
• Generate and analyze audit reports to identify adjudication errors, overpayments, and underpayments.
• Document audit findings with detailed review process, justification, and conclusions.
• Track and analyze errors to identify trends and recommend training or system enhancements.
• Provide training and mentoring for new staff to improve accuracy and productivity.
• Maintain detailed knowledge of EZ-CAP rules related to claims payment.
• Ensure compliance with claim timeliness standards.
• Collaborate with the Recovery Team on overpayment resolution.
• Perform Coordination of Benefits (COB) reviews as applicable.
• Support overall business needs of the Claims Department and contribute to team goals.
• Consistently meet productivity and quality standards as defined by management.

Kenntnisse

Claims coding

EZ-CAP

Microsoft Word

Microsoft Excel

Attention to detail

Analytical skills

Communication skills

Independent worker

Jobbeschreibung

Imperial Health Plan is seeking a Claims Auditor to review and audit claims adjudicated by the system and examiners prior to check runs. You will verify compliance with CMS, Medi-Cal, and commercial guidelines, identify errors, and provide recommendations for process improvements.

The role requires 2+ years in complex claims processing or auditing, with EZ-CAP knowledge preferred. Strong analytic, communication, and multitasking abilities are essential in a fast-paced environment.