Claims Auditor - Chula Vista, United States - Community Health Group

Community Health Group Chula Vista, United States

3 weeks ago

Description

Job Details

Job Location
Corporate Headquarters - Chula Vista, CA

Salary Range
$ $27.71 Hourly

Description

POSITION SUMMARY

Promotes and maintains the quality and accuracy rate of claims paid by CommunityHealth Group. Conducts pre-disbursement audits for fee for service claims. The Claims Auditor compiles, tracks and trends audit results and recommends suggests training and other improvement ideas.

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations.

RESPONSIBILITIES

Conducts pre-disbursement audits (quality review) of targeted claims, providers, or processes, such as interest payment, misdirected claims, auto adjudicated claims, etc.
Analyzes data to identify processing errors, inappropriate billing, and possible fraud for services provided.
Acts as back up to the VE Claims Auditors and performs the functions related to this position.
Provides recommendations for staff training based on processing irregularities identified through the claims audit process.
Submits recommendations for provider training and other appropriate action based on audit findings.
Assess information from a variety of sources and generate weekly, monthly, and quarterly trend reports.
Audits all claims with payment amounts over $5,000 for Professional claims and $10,000 for Hospital claims.
Identifies errors, billing inconsistencies, and system configuration issues and reports these to Claims Audits Supervisor for further investigation and follow up.
Completes tort liability reporting. Compile all necessary Third Party Liability claims information and submit to Department of Health Services, Third Party Liability Division.
Maintains product and company reputation and contribute to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

Qualifications

EDUCATION

AA degree
Coding and/or medical terminology certificate

EXPERIENCE/ SKILLS

A minimum of five years of experience analyzing and processing claims
Strong knowledge of Medi-Cal and Medicare payment guidelines
Solid healthcare and managed care background
Vast knowledge in claims coding and auditing
Clear understanding of medical record review
Ability to handle confidential, sensitive information with professionalism
Proficiency in Microsoft Office
Excellent verbal, written, organizational, and analytical skills

PHYSICAL REQUIREMENTS

Prolonged periods of sitting

Community Health Group is an equal opportunity employer that is committed to diversity and inclusion in the workplace. We prohibit discrimination and harassment based on any protected characteristic as outlined by federal, state, or local laws. This policy applies to all employment practices within our organization, including hiring, recruiting, promotion, termination, layoff, recall, leave of absence, compensation, benefits, and trainings. Community Health Group makes hiring decisions based solely on qualifications, merit, and business needs at the time. For more information, see Personnel Policy 3101 Equal Employment Opportunity/Affirmative Action.

Claims Auditor

4 days ago

Community Health Group Chula Vista, United States

Job Details · Job Location · Corporate Headquarters - Chula Vista, CA · Salary Range · $ $27.71 Hourly · Description · POSITION SUMMARY · Promotes and maintains the quality and accuracy rate of claims paid by CommunityHealth Group. Conducts pre-disbursement audits for fee fo ...
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POSITION SUMMARY · Promotes and maintains the quality and accuracy rate of claims paid by Community Health Group. Conducts pre-disbursement audits for fee for service claims. The Claims Auditor compiles, tracks and trends audit results and recommends suggests training and other ...
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