Claims Auditor

Our Mission.. Kern Health Systems is dedicated to improving the health status of our members through an integrated managed health care delivery system. Definition Under limited supervision this position is responsible for auditing a percentage of all types of medical and facility claims from contracting and non-contracting providers and from subscribers and enrollees.  Responsibility includes determining the percentage of claims to be pulled for each adjudicator; reviewing processed claims for accuracy in a fast paced environment; detect error trends and working to provide these trends for claims management.   Distinguishing Characteristics The key purpose of this auditing position is to reduce claims processing error rate through the reduction in claims under/overpayment and claims denied in error.  This position requires the ability to work with an adjudication system for claims review, an audit queue of claims waiting review and an imaging system for review of the submitted HCFA, UB or EDI claim.  An understanding of the requirements of healthcare under a Knox-Keene licensed health maintenance organization (HMO).   Essential Functions • Work through an audit queue of processed claims. • Review claims processed through the claims system (QNXT) for accuracy.  • Detect and provide corrective actions for claims paid inappropriately or inappropriately denied. • Provide clear and concise explanation of errors found with recommended corrective action back to an adjudicator including research results for training and reference information.  • Look for error trends to assist in adjudicator improvements either through training or supervisor oversight. • Report error trends to supervisor. • Work with the claims management team on staff improvements. • Assist in internal audit review of claims accuracy rates. • Prepare monthly audit report for management staff • Work with MIS staff on process flow improvements along with increasing functionality for audit tracking, to include enhanced reporting capabilities. Other Functions • Maintain productivity and quality in accordance with established guidelines. • Perform other job-related duties as required. • Adheres to all company policies and procedures relative to employment and job responsibilities. Employment Standards:  High school diploma from an accredited school or equivalent.  Minimum of four (4) years of medical claim payment or medical billing processing experience.  Prefer two (2) years’ experience performing claims review for error tracking. Knowledge of:  computerized on-line data entry systems; organizational structure of medical claims processing; methods and procedures utilized in medical claims processing; medical terminology; CPT & Diagnosis coding; COB & subrogation investigation; clear understanding of HCFA and UB claim forms.  Experience with Microsoft Word and Excel programs. Ability to:  adapt to a rapidly evolving work environment; work independently; communicate with a variety of personnel; detect claims processing errors using existing company systems; make recommendation of corrective claims processing; communicate effectively and efficiently in error resolution and trend analysis.

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