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Job Details

Claims Quality Auditor Int

Location
Englewood, CO

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Quality Claims Auditor: This position exists to ensure the integrity of outside medical payments for the organization through verification of the accuracy of data-entered information & by auditing service related information & invoice adjudication/payment for compliance w/ contract terms & Department/Regional policy & procedures. The auditor must be thoroughly familiar w/ outside medical systems & claims processing/adjudication processes. The Auditor must independently perform comprehensive audits of claims to source documents & identify inaccuracies. Conduct quality audits of claims, pre & post payments, utilizing appropriate sources of information, including eligibility, enrollment, provider contracts, policy & procedures. The position requires research, problem resolution & specialized knowledge in the areas of contracts, Medicare & Medi-Cal regulations & reimbursement rules, Multiplan & Beechstreet, Worker's Compensation, Coordination of Benefits & Third Party liability. The auditor must also be capable of developing a working relationship w/ regulatory agencies. The level of involvement depends on the specific location. Ensures timely intervention into the service quality issues in order to enhance service delivery & customer satisfaction.

Essential Functions

  • Conduct quality assurance audits for all lines of business. Access the mainframe system to review each claim image to the actual data input into the system & claim payment to ensure accuracy. Benefits, coverage, eligibility are all verified.
  • Conduct quality assurance audits for Vantive cases, adjustments, refunds & provider disputes. Review each claim image to the actual data input into the system & claim payment to ensure accuracy.
  • In-services staff members on new & existing policies & procedures. Each auditor is assigned to an Operations team in which the Auditor prepares weekly reviews of the quality. When trends or patterns are identified, the Auditor attends the Daily Dialogue for assigned team & reviews the errors as well as the best practice w/ the Examiners.
  • Participate in appropriate & approved training classes during year (in accordance w/ goals). Auditors attend all training claim processing classes to ensure they have the most updated processes.
  • Full use of application of standard principles, theories, & techniques.
  • Uses professional concepts & company policies & procedures to solve a wide range of difficult problems in imaginative & practical ways. The Auditors perform detail audits for which they use the current P&P to drive audits decisions. Auditors often must utilize outside resources to obtain required information such as State or Federal mandates that impact the claim payment, such as CMS website pricers.
  • Awareness of work required at next level & working at that standard.
  • Works on problems of moderate scope where analysis of situations or data requires a review of variety of factors. During the audit process the Auditor performs analysis on each claim to determine the root cause of the identified error.
  • Exercises judgment w/in defined procedures & practices to determine appropriate action. At times the documented process may not be clear or even be conflicting, the Auditor must research the correct process & base their audit on the best practice which may not always be the documented process.
  • Builds productive working relationships internally & externally. Auditors work closely w/ various CCA departments such as Operations, Training & Compliance to ensure lines of communication are kept open w/ processing or auditing related issues.
  • This job description is not all encompassing.

    Basic Qualifications:
    Experience
  • Minimum three (3) years of claims processing with minimum two (2) years of claims auditing experience.
    Education
  • Bachelor's degree in related field, OR four (4) years of experience in a directly related field.
  • High School Diploma or General Education Development (GED) required.
    License, Certification, Registration
  • N/A.

    Additional Requirements:
  • Intermediate competency in MS Applications (Excel, Access, PowerPoint), outstanding ability with proprietary and mainframe processing systems KP technologies.
  • Internal candidates should meet or exceed performance metrics for four (4) or more quarters.
  • Able to discuss mission, vision and objectives within own department and unit.
  • Describes company philosophy, culture and history.
  • Discusses the roles and responsibilities of major business units and department's operating principles and practices.
  • Able to identify and discuss key players, key issues and strategies.
  • Must be able to work in a Labor/Management Partnership environment.




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