Job Description

The Sr 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.

Minimum Requirements

  • 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

Abilities Required

  • 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