The Claims Auditor ensures incoming claims are processed in accordance with policies, procedures and guidelines, as outlined by Leon Health and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts. The Claims Auditor will be responsible for pre-payment, post-payment validations and the management of operational reporting, testing and data submissions.
Summary of Essential Duties and Responsibilities
- Apply Medicare Claim Payment rules and requirements, including the application of National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements to claims received for payment.
- Enter claim data accurately and timely, in alignment with departmental production and quality goals
- Ensure claims payments are made within time frames as reflected in contractual agreements
- Maintain a minimum of 98% accuracy at all times
- Perform pre-payment audits and post payment audits to validate claims for appropriate coding and documentation (including but not limited to CPT, HCPCS, ICD-10 coding) and validate accurate claim adjudication rules and fee schedules were applied
- Perform pre-payment high dollar claim audits
- Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with Leon Health contractual guidelines
- Manage difficult, non-routine or escalated claims by using comprehensive research and thorough knowledge of Medicare payment rules
- Identify and manage third party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers or members. Perform outreach and recovery efforts to Third Party Administrators.
- Coordinate with Finance department for claim payments, voids and refunds. Apply adjustments to the claim payment system as necessary.
- Refer claims for medical management claim review as necessary/applicable.
- Outreach to providers for additional information, including medical records to validate Medicare criteria is met prior to approving a claim for payment.
- Educate providers on billing requirements to reduce claim submission rejections and denials. Educate providers on prior authorization requirements.
- Review and process provider payment disputes according to Leon Health policies and contractual requirements.
- Review and process member requests for reimbursement of claims.
- Create and distribute claim inventory and aging reports as needed. Create ad hoc claim data extracts as needed.
- Create and validate claim reports (Organizational Determinations) prior to submission to CMS to ensure accuracy and completeness of data files
- Assist in the effectuation of overturned appeals made by Leon Health or federal contractor/entity
- Assist in the research and resolution of payment disputes and appeals
- Assist in the creation of case files for the QIO, IRE or other state or federal entity upon request
- Identify and refer potential fraud and abuse cases to the Compliance Department
- Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs
- Identify opportunities for claims adjudication process improvements
- Perform User Acceptance Testing and support implementation of tools and systems for the Claims Department
- Assist in the training of new staff on claims processing policies, procedures and systems
- Filing and light administrative duties associated with claims processing
- Other duties and responsibilities as may be assigned.
- High School diploma or GED equivalent; Associates degree in a related field is preferred
- Minimum of five years’ experience in healthcare claims processing, or an equivalent combination of education, training and experience
- Medicaid and Medicare claim processing experience preferred
- Strong understanding of claims processing workflow and payment rules
- Computer proficiency in a Windows environment, knowledge of Microsoft Office products with an emphasis in Excel.
- Detailed knowledge of electronic billing processes and universal billing forms (UB04, CMS-1500)
- Strong knowledge of medical terminology, CPT Codes, HCPCs codes and ICD-10
- Knowledge of CMS pricers and vendor pricing software
- Strong written skills to accurately complete required documentation within the time frames specified
- Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames
- Ability to read, write and communicate at a professional level
- Effective time management and organizational skills
- Effective interpersonal and communication skills
Job Status: Full Time