CLAIMS AUDITOR
Company: Hoag Hospital Irvine
Location: Costa Mesa
Posted on: November 17, 2023
|
|
Job Description:
Select how often (in days) to receive an alert: Create Alert
Salary Range: -$23.1800 -- -$35.6200 -/hour. Actual compensation
may vary based on geographic location, work experience, skill
level, and education. Job Summary: - The Claims Auditor is
responsible for performing pre-payment and post-payment audits
ensuring financial and processing accuracy, compliance with
regulatory and health plan requirements of claims processed. The
Claims Auditor is responsible for auditing and confirming accuracy
of the loading of fee schedules, provider contracts, payor
contracts, benefits, code changes, and system enhancements.
Essential Functions: - Conducts pre and post payment adjudication
audits of claims and may adjudicate high dollar claims and member
denials - Meet key metrics on productivity, financial accuracy, and
regulatory compliance - Confirm patient eligibility and application
of Coordination of Benefits guidelines by partnering with the
Enrollment and Eligibility team - Review member benefits, contract
terms with medical providers, utilizes various fee schedules and
payment terms (FFS, case rates, exclusions, carve-outs, capitation,
per diems, stop loss, etc.) and health plans/Division of Financial
Responsibility, timely filing, and regulatory compliance guidelines
durin the audit process - Identify root cause in order to avoid or
minimize re-work and address front-end process issues by initiating
requests for system correction, process flow enhancement, or team
training - Completes and maintains detailed documentation of audit
including citing regulatory, industry, or department guidelines for
financial reporting and trending analysis - Identifies overpayments
and coordinates with Revenue Recovery team for refund and
recoupment process - Audit and confirm accuracy of loading of fee
schedules, provider contracts, payor contracts, benefits, code
changes, and system enhancements. - Analyze health plan capitation
deductions and demands and coordinate with Hoag Managed Care, Hoag
Finance, and health plan contacts to dispute and resolve issues -
Review overpayment requests from claim audits, refunds received
(voluntary and involuntary), eligibility guarantee, retro
eligibility terminations, and facilitate the resolution,
collection, recoupment, and posting of monies collected. - Interact
in a positive and collaborative manner with internal and external
partners. Alert the claims management team of issues and trends
observed in the audit process. - Resolve requests from providers,
patients, and health plans on claims questions - Support the claims
team in implementing initiatives in improving claims processing
efficiency - Specialize in the end-to-end process of claims
adjudication to include having strong knowledge of processing all
service types, provider types, and lines of business - Assist in
resolving escalated issues from provider customer service, member
services, health plan, and other customers including making and
answering phone calls to providers/billing offices when necessary
based on team guidelines - Assist in completing special projects
related to provider and plan JOCs, system upgrades, etc. - Mentor
on the team that leads aspects of training function - Subject
matter expert in a variety of knowledge sets and process
improvement activities - Perform other duties as assigned
Education, Training and Experience: Required: High School Diploma
or equivalent, 5 years of experience in a medical claims
processing, environment, knowledge of HMO/managed care regulatory
guidelinesPreferred: Experience with Epic Tapestry system, 3 years
experience in claim audits, revenue recovery, or claims system
configuration
Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles
Job Segment: Compliance, Front End, EMR, Business Process, Law,
Legal, Technology, Healthcare, Management Hoag is where exceptional
people with full hearts strive to make a difference. Start your
career, make an impact, and join our family.Join our Talent
Community and be the first to know about new Hoag job
opportunities!
#J-18808-Ljbffr
Keywords: Hoag Hospital Irvine, Costa Mesa , CLAIMS AUDITOR, Accounting, Auditing , Costa Mesa, California
Click
here to apply!
|