Claims Quality Auditor

Claims Quality Auditor
Department:

Claims
Effective Date:

July 20, 2023

Reports to:

Claims Adjudication Supervisor
Direct Reports:

None
FLSA:

Non-exempt

Working Conditions: Normal, no adverse or hazardous conditions.

Our established Medical Management Company is built on more than 100 years of collective

experience in the managed care (healthcare) industry. We specialize in managing

independent groups of physicians with commercial, MediCal and senior managed care

(HMO) patients.

We are looking for a super star candidate as our full-time, Claims Quality Auditor, who will be

responsible for providing a high level of service to IPA’s clients, including members, providers,

third party provider representatives, and health plans.

Primary Purpose:

To ensure the Claims Department is processing claims accurately and in accordance with

DMHC, CMS and Health Plan guidelines.

Principal Duties and Responsibilities ( = essential functions):

To prioritize claims utilizing the Company’s in-house claims processing system.

To verify patient’s accounts for eligibility and benefits.

To process appeals and Provider disputes accurately; and apply interest where

applicable

To accurately process claims that have been accepted for payment.

To request and follow-up on additional information as needed for incomplete claims.

To complete all steps above within designated timeframes and notify management if

claims cannot be processed timely.

To treat peers, superiors, subordinates, clients and vendors with fairness, courtesy and

professionalism and contribute to the overall positive work environment of the

department and the Company.

To accurately interpret DOFRs – Division of Financial Responsibility documents that

determine who pays for specific health care services (PDT, health plan or other).

To complete other production projects as assigned by supervisor.

To complete other tasks as assigned.

Job Specifications (KSAs):

Five or more years practical work experience in a managed care claims environment.

Must have strong organization and communication skills.

Position Requirements:

Knowledge of health care industry and/or managed care claims processing as

generally gained through 1-2 years of experience.

Requires the ability to speak, read, write and understand English and other

general educational skills as obtained by completing high school or a GED.

Possess knowledge of medical claim forms for institutional/facility claims (UB

04/CMS 1450) and professional claims (CMS 1500).