Claims Auditor Job Description

Claims Auditor Job Description

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Claims auditor provides education to internal staff and external providers based on audit findings; provides general education on ICD-10, HCPCS and CPT codes as appropriate.

Claims Auditor Duties & Responsibilities

To write an effective claims auditor job description, begin by listing detailed duties, responsibilities and expectations. We have included claims auditor job description templates that you can modify and use.

Sample responsibilities for this position include:

Reviewing the company’s processing logic to extract the specific circumstances under which services are covered
Thoroughly documenting the coverage details
Learn how to read basic commands of the claims processing logic
Develop a strong grasp of the process for documenting the audits findings
Become an expert in the process of extracting coverage details from the claims logic for procedure topics
Complete an audit of 35-40 pre-assigned procedure topics
Document the audit� processes and standardize the output of the audit
Responsible for all team training including but not limited to new hires, cross training, new product and system enhancements
Conducts audits for new hires and/or any team member learning a new skill
Reviews, interprets and maintains records of quality and productivity for entire team

Claims Auditor Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Claims Auditor

List any licenses or certifications required by the position: ICD10, MUST, AAPC

Education for Claims Auditor

Typically a job would require a certain level of education.

Employers hiring for the claims auditor job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Associates, Business, Pharmacy, Medical, Technical, Auditing, Business/Administration, Finance, Accounting

Skills for Claims Auditor

Desired skills for claims auditor include:

CPT
HCPCS codes
APCs
HCPCS and ICD-9 codes and modifiers
MSDRG
Microsoft Suite of products
Revenue codes
UB04 and medical claim formats and requirements
CPT codes
DRGs

Desired experience for claims auditor includes:

Completion of an audit of 35 to 40 pre-assigned procedure topics
Prior experience working in a MAC environment
2+ years of previous medical claims auditing experience required
Coaches, mentors and develops associates to ensure processes, guidelines and tools are utilized correctly
Utilizes inventory management strategies to monitor priorities and ensure timely turnaround of all claims
Responsible for creating, updating and maintaining departmental policy and claims auditor procedure manuals for accuracy

Claims Auditor Examples

1

Claims Auditor Job Description

Job Description Example
Our innovative and growing company is looking for a claims auditor. To join our growing team, please review the list of responsibilities and qualifications.
Responsibilities for claims auditor
  • Serves as subject matter expert on policy, workflow and technical questions
  • Partners with Management on complex claims reviews and resolution
  • Responsible for reviewing and resolving shared mailbox issues
  • Interprets contracts, prepares monthly reports, and attends meetings as subject matter expert when requested
  • Manages projects as assigned and may work across different platforms or lines of business
  • Reviews and responds to external audit requests
  • Performs audit reviews of and may adjudicate complex high dollar claims by completing an end to end audit with final approval authority
  • Evaluates the quality and accuracy of transactions and/or communications with providers, groups, and/or policyholders
  • Tracks and trends audit results, providing feedback to management
  • Identifies and reports on systemic issues which create ongoing quality concerns
Qualifications for claims auditor
  • Understanding the process for documenting the audit�s findings
  • Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested
  • Produces other ad hoc reports as requested by internal and external clients
  • Associates at this level conduct routine to complex audits, generally related to functions on systems platform for lines of business
  • Assesses and validates that all regulatory health plan requirements are adhered to in the processing of claims transactions with delegated entities
  • Responsible for the development and implementation of Improvement Action Plans to drive execution of remediation activities
2

Claims Auditor Job Description

Job Description Example
Our growing company is searching for experienced candidates for the position of claims auditor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claims auditor
  • Performs oversight-monitoring activities for the delegates, including analysis of monthly reports, conducting trending analysis and review of Monthly Timeliness Reports
  • Applies McKesson Claim Check software daily report edits to flag claims for correction
  • Validate the accuracy of clinical medical record reviews and payment decisions
  • Develop and deliver fact based audit determinations
  • Serve on applicable cross-functional quality committees and work groups to identify and communicate common quality issues, trends, and patterns
  • Selects providers to be reviewed based on historical results of other reviews with providers, network management input and dollar volume of provider
  • Schedules review with provider, analyzes data to select claims to be reviewed, conducts review using medical charts, medical notes, itemized bills and provider contracts
  • Conducts exit interview with provider management team by presenting preliminary review results
  • Verifies dollar amount on claim is correct in claims system and writes report of the findings of the review and requests payments for any overpayments
  • Identifies aberrant patterns of billing and detects potential abuse
Qualifications for claims auditor
  • Auditor will receive a copy of the SPD and adjudication procedures for review and reference of the respective benefit plan to be audited
  • Using the payer’s claims system, the auditors must manually process the claim from receipt to check release and identify any inconsistencies in financial payment and/or procedural compliance with established procedures and industry best practices
  • 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
  • Listens actively and demonstrates sensitivity to staff members/customers, encouraging them to discuss concerns, interests, needs and difficult issues
  • Consistently monitors own work and seeks further experiences to ensure continual quality patient/customer service delivery
3

Claims Auditor Job Description

Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of claims auditor. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for claims auditor
  • Drafts department policies and procedures and other educational materials
  • Works on task forces and committees representing functional area
  • Responsible for daily Check Run analysis and communication to Account Management related to totals outside of weekly average
  • Review a minimum of 85 processed claims per day (425 per week) for HealthPlan and ESD minimum of 65 processed claims per day (325 per week) for Government Program to ensure accuracy in accordance with established policies and procedures in the CAS/SCC claims processing system on a daily basis
  • Performs oversight-monitoring activities for the delegates, including analysis of monthly reports, conducting trending analysis and review of Monthly Timeliness Reports Facilitates ad-hoc meeting with delegates to discuss and proactively address identified issues
  • Completes V2 auditing of claims
  • Coordinates outgoing Preferred Accounts email programs with the National Retail Incentives Specialist
  • Handles incoming escalations received from Preferred Accounts regarding control number issues, seeking direction from National Retail Incentives Specialist, as required
  • Assists with handling escalations required for claim issues
  • Handles manual claims adjustments
Qualifications for claims auditor
  • Experience analyzing data and proposing remediation, developing Corrective Action Plans in all variety of mediums (verbal, writing, PowerPoint) to a broad audience level across an Organization
  • Puts forward ideas assertively and directly influencing others to identified issues and concerns
  • Adapts ideas well and ties them to the needs and goals of others in order to gain their support and commitment
  • Minimum three (3) years experience in a broad medical/surgical background and two (2) years experience in medical auditing
  • 1+ years with MS Excel- (creating, saving, formatting documents, pivot tables)
  • Medical coding certification with AAPC (American Academy of Professional Coders) or AHIMA (American Health Information Management Association)
4

Claims Auditor Job Description

Job Description Example
Our growing company is looking to fill the role of claims auditor. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims auditor
  • Manage the claims internal audit functions, which includes audit process for adjudicated claims and encounters
  • Monitor check run process for accuracy
  • Develop policies and procedures for periodic claims audits and ensure compliance with affiliated health plans, client groups, and administrative contractual agreements
  • Designs, plans, directs and implements claims training programs for the organization, to include adaptations to changes in policies, procedures and technologies
  • Must be familiar with applicable State and Federal claim payment and denial timeliness legislation
  • Must be familiar with Timeliness Compliance pursuant to State and Federal rules and regulations
  • Must be well versed regarding the Provider Dispute Resolution tracking mechanism (AB1455)
  • Responsible for ensuring customer (provider-vendor) satisfaction while maintaining the integrity of Facey's vision and business objectives
  • Demonstrates a high level of integrity and innovative thinking and actively contributes to the success of the Team
  • Supports, encourages and models attitudes, actions and behaviors that will make Facey the best in the industry in customer measured quality and responsiveness requirements
Qualifications for claims auditor
  • Excellent mathematical, written and verbal skills and demonstrated medical terminology competence
  • A proven ability to think and act independently and professionally
  • Able to understand, develop and implement procedures
  • Certification in a clinical practice or medical coding or provider reimbursement auditing or 5 years equivalent work experience
  • Recent experience in insurance/healthcare industry to support our clients
  • 8+ years successful experience in a claims auditing role
5

Claims Auditor Job Description

Job Description Example
Our growing company is looking for a claims auditor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claims auditor
  • Provides day-to-day assistance and training on Claims compliance matters to the Claims Examiners and Adjudication teams
  • Compares TPA paid premium to established rates as defined in the Administration agreement
  • Researches claim processing problems and errors to determine their origin and appropriate resolution
  • Mentors and oversees work of less experienced staff
  • Designs complex audits and provides strategic direction for the design and execution of testing plans to analyze and evaluate risks and controls around Enterprise objectives
  • Coordinates the analysis of risk and controls and provides recommendations for appropriate action by business partners
  • Ability to clearly communicate risk management and control issues identified in audit reports, proactively recommends the most appropriate/effective resolutions and presents audit reports effectively to management
  • Identifies and recommends enhancements of Audit and internal control systems by updating audit programs and procedures
  • Assist in researching state workers’ compensation laws that impact audits
  • Train claims and customer service staff on systems and procedures responding to their questions as needed
Qualifications for claims auditor
  • 3 years of work experience in a customer-facing role
  • Automotive environment ideal
  • Extensive experience in health insurance claims processing with a minimum of 3 to 5 years of experience
  • Minimum of 2 years of experience in provider, benefit, pricing or rules configuration on Aldera core system required
  • Expert knowledge of Aldera configuration (provider, benefit, pricing or rules)
  • Executive presence with ability to develop and present executive overview and presentations

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