- Conduct quality audits for Claims exceeding the processor's payment authority in accordance with policy provisions and internal guidelines.
- Conduct quality and weekly/monthly random audits for Claims Analyst, Claims Adjuster, Payment Specialist, ensuring that a minimum of items are audited per Department each week/month.
- Conduct monthly random audits for various high-profile clients.
- Review Surcharge Reports and complete Waiting Approval along with Premium Specialists Audits.
- Reply to MTM Audit Requests.
- Complete any required high dollar notifications.
- Complete required stop loss filings.
- Assist with BCBS Association LDLA Audits.
When auditing for BCBS Global Core: - Conduct quality audits for claims exceeding the processor's payment authority in accordance with the BCBS Global Core requirements and internal guidelines.
- Conduct monthly random audits for Claim Analyst and Claim Adjustors ensuring that a minimum of 10 items are audited per person each month.
- Complete the monthly Association quality report.
When auditing for Federal Employee Program (FEP): - Conduct quality audits for claims exceeding the processor's payment authority in accordance with the FEP requirements and internal guidelines.
- Conduct monthly random audits for Claim Analyst and Claim Adjustors ensuring that a statistically valid sampling of claims is audited per person each month (approximately 10 claims per person).
- Complete the monthly FEP quality reporting.
- Provide trending analysis data to management monthly.
- Follow regulations and company rules and policies, as outlined in the Employee Handbook.
- Other duties as assigned.
- High school diploma or equivalent. Some college/degree a plus.
- Minimum - five years' experience in the health insurance industry examining and adjudicating medical claims with exposure to plan features and benefits in resolving claims related issues.
- Familiarity with insurance products, standard medical policy, and insurance terminology, including CPT and ICD-10 coding. Coding Certificate desired for FEP (CPC, CCS).
- Ability to use automated claims adjudication software.
- Good verbal and written communication skills and ability to effectively deal with customer complaints and concerns.
- Work organization, problem solving, and basic math skills.
- Ability to make decisions and support them with documentation.
- Operate standard office equipment (telephone, copier, fax, personal computer, etc.) and familiarity with Microsoft Office products.
- Employee is required to have at minimum an internet speed of 75 Mbps (standard high-speed internet access).
- Flexibility to work in an office and/or at -home, remote office environment.
- Schedule flexibility is occasionally necessary in this position. Individual may be required to attend key business/departmental meetings and/or perform certain business critical job functions outside of normal working hours.
- Physical Demands: Must be able to communicate internally and externally through receiving and responding to auditory and visual methods.
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Claims Audit Analyst - King of Prussia, United States - Worldwide Insurance Services
Description
Job Description
Job DescriptionWe are hiring for a Claims Audit Analyst to join the team The Claims Audit Analyst is responsible for conducting timely quality audits and for providing audit performance data to management for department monthly statistic reporting.
Responsibilities:
When auditing for Classic:
Requirements:
Working Conditions:
Internal Pay Grade: 7
The starting pay for this role is $45,465 to $56,832 based on skill level and experience in a similar role.
This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned.
