Claims Auditor II

November 7

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Martin's Point Health Care

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TRICARE Prime • Medicare Advantage • Medicare Part D • Health Care • Primary Care

501 - 1000 employees

⚕️ Healthcare Insurance

🧘 Wellness

Description

• Under the supervision of the Director of Health Plan Operations, the Claims Auditor II will perform the following job functions: • Audit Development and Processing: The Auditor II will be responsible for developing and processing audits, as assigned. • Interdepartmental Liaison: The Auditor II will be responsible for supporting the Manager of the Audit Department, as directed, in liaising with other departments within Martin’s Point. • External Liaison: The Auditor II will be responsible, as assigned, for communicating with providers and other entities, outside of Martin’s Point, either verbally or through written communications, regarding questions related to claims, claims audits or other matters directed to the Audit Department. • Planning and Reporting: The Auditor II will support, as directed, the Manager of Audit in carrying out audit development planning, reporting, and root cause administration. • Key Outcomes: Research regulatory authority to identify incorrect payment methodologies resulting in claims overpayments. • Research skills are to include the abilities to perform and complete research of complex reimbursement policy issues. • Analysis of program benefit documents to identify inconsistent claims payments or payment policies. • Research, design, and development of audit formats to identify claims overpayment scenarios, from basic to complex. • Liaise with departmental data analysts in the preparation, extraction and validation of data used in overpayment research and auditing activities. • Support of auditors, regarding audit development activities and audit processing. • Perform claims audits to identify and recover claims overpayments. • Prepare necessary summary materials for use by the Audit Department and other departments in audit finalization follow-up processes. • Provide detailed support to other departments in connection with audit related activities. • Participate, as directed, in developing root cause analysis reports and remediation programs related to audit findings. • Assist departmental management in the preparation of revenue projections, policies, technology recommendations and other departmental materials. • Provide support to others within the company regarding claims administration, procedural coding and billing and related overpayment matters. • Provide response and follow-up, either written or verbal, to audit related provider or other inquiries. • Prepare reports and communications for management relating to claims overpayment and claims administration matters. • Represent the Audit Department on interdepartmental committees and work-groups.

Requirements

• Bachelor of Arts or Science degree or equivalent combination of education and relevant experience. • 5 or more years of related medical claims auditing experience or equivalent experience. • Detailed knowledge of CPT-4, ICD-9, HCPCS, and Revenue Coding required. • Training related to ICD-10 is recommended. • Strong computer skills including the use of data management programs such as Excel and Access. • Strong proficiency in MS Office programs including Power Point is recommended. • Certified Professional Coder (CPC) certification or other equivalent certification.