Claims Auditor

JOB DESCRIPTION JOB TITLE

Claims Auditor

FLSA STATUS

Non-Exempt

DEPARTMENT

Claims Audit

REPORTS TO

Claims Audit Manager / Claims Director

JOB SUMMARY

The Claims Auditor is responsible for reviewing and auditing claims adjudicated by the system and claims examiners prior to check runs. This role ensures accuracy, identifies errors, verifies compliance with regulatory requirements, and provides recommendations for process and system improvements. The Claims Auditor also supports cross-departmental initiatives to maintain payment integrity and compliance with CMS, Medi-Cal, and commercial guidelines.

ESSENTIAL JOB FUNCTIONS

Accurately apply Health Plan Benefit Matrices and DOFR (Division of Financial Responsibility) 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:

Commercial:

45 working days

Medi-Cal:

30 calendar days Medicare non-contracted: 30 calendar days

Medicare Contracted:

60 calendar days 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.

MARGINAL JOB FUNCTIONS

Take on special projects as needed. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS

Continuous Learning:

a. Attend required staff meetings. b. Participate in relevant training, seminars, and workshops to stay informed and up to date.

Customer Focus:

Maintain client/customer confidentiality and privacy in compliance with HIPAA regulations and IMAS's Standards of Conduct. Foster effective communication and collaboration with supervisors, co-workers, and other staff members. Quality/Process Improvement/Safety a. Report any security, health, or safety issues to the appropriate supervisor as soon as possible. b. Demonstrate a commitment to safety in all duties performed. c. Follow established policies, procedures, and comply with all regulatory standards set by governing entities.

POSITION REQUIREMENTS

EDUCATION/EXPERIENCE:

Minimum 2 years' experience in complex claims processing and/or auditing in the health insurance industry. EZ-CAP knowledge strongly preferred.

SKILLS/KNOWLEDGE/ABILITY

Strong knowledge of healthcare regulations and guidelines (CMS, DMHC, DHS). Proficiency in claims coding and forms (CCI, CMS-1500, UB-04, CPT, ICD-10, HCPCS). Familiarity with EZ-CAP or similar claims processing systems. Proficiency in Microsoft Word and Excel; basic understanding of medical terminology. Excellent organizational, multitasking, and deadline management skills. Strong analytical and problem-solving abilities with keen attention to detail. Ability to exercise sound judgment and work independently or collaboratively. Strong written and verbal communication skills. Ability to multitask and effectively solve problems in a fast-paced work environment. Proficiency in reading, writing, speaking, and understanding English, with the necessary communication skills to provide accurate information to residents and staff. Ability to follow both written and verbal instructions in English. Commitment to maintaining appropriate levels of confidentiality and privacy in all interactions. Professional demeanor and ability to interact courteously with customers, members, and co-workers, both independently and as part of a team. Ability to effectively manage multiple tasks and adapt to shifting priorities as required. Strong decision-making and problem-solving skills, with the ability to make appropriate judgments in a timely manner. Ability to prioritize tasks effectively, ensuring that key items are addressed efficiently. Self-motivated and capable of taking initiative as a self-starter. Willingness and ability to understand and comply with all relevant Federal, State, and local regulations.

LICENSURE/CERTIFICATE/TRAINING

n/a