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Department:  Business Services
Status:  Full Time
Shift:  1st

Job Summary: 

The Claims Auditor is responsible for performing pre-payment and post-payment audits ensuring financial and processing accuracy, compliance with regulatory and health plan requirements of claims processed. The Claims Auditor is responsible for auditing and confirming accuracy of the loading of fee schedules, provider contracts, payor contracts, benefits, code changes, and system enhancements.


Essential Functions

· Conducts pre and post-payment adjudication audits of claims and may adjudicate high dollar claims and member denials

· Meet key metrics on productivity, financial accuracy, and regulatory compliance

· Confirm patient eligibility and application of Coordination of Benefits guidelines by partnering with the Enrollment and Eligibility team

· Review member benefits, contract terms with medical providers, utilizes various fee schedules and payment terms (FFS, case rates, exclusions, carve-outs, capitation, per diems, stop loss, etc.) and health plans/Division of Financial Responsibility, timely filing, and regulatory compliance guidelines durin the audit process

· Identify root cause in order to avoid or minimize re-work and address front-end process issues by initiating requests for system correction, process flow enhancement, or team training

· Completes and maintains detailed documentation of audit including citing regulatory, industry, or department guidelines for financial reporting and trending analysis

· Identifies overpayments and coordinates with Revenue Recovery team for refund and recoupment process

· Audit and confirm accuracy of loading of fee schedules, provider contracts, payor contracts, benefits, code changes, and system enhancements.

· Analyze health plan capitation deductions and demands and coordinate with Hoag Managed Care, Hoag Finance, and health plan contacts to dispute and resolve issues

· Review overpayment requests from claim audits, refunds received (voluntary and involuntary), eligibility guarantee, retro eligibility terminations, and facilitate the resolution, collection, recoupment, and posting of monies collected.

· Interact in a positive and collaborative manner with internal and external partners. Alert the claims management team of issues and trends observed in the audit process.

· Resolve requests from providers, patients, and health plans on claims questions

· Support the claims team in implementing initiatives in improving claims processing efficiency

· Specialize in the end-to-end process of claims adjudication to include having strong knowledge of processing all service types, provider types, and lines of business

· Assist in resolving escalated issues from provider customer service, member services, health plan, and other customers including making and answering phone calls to providers/billing offices when necessary based on team guidelines

· Assist in completing special projects related to provider and plan JOCs, system upgrades, etc.

· Mentor on the team that leads aspects of training function

· Subject matter expert in a variety of knowledge sets and process improvement activities

· Perform other duties as assigned



Education, Training and Experience Required: High School Diploma or equivalent, 5 years of experience in a medical claims processing, environment, knowledge of HMO/managed care regulatory guidelines Preferred: Experience with Epic Tapestry system, 3 years experience in claim audits, revenue recovery, or claims system configuration


Skills or Other Qualifications Required: Strong moral compass and commitment to Hoag’s values Motivated to learn, continually improve and operate to one’s fullest potential Positive attitude, passionate, excited, strong desire to simplify processes. Experience in providing excellent customer service, empathetic ability Skills to multi-task and manage competing priorities, apply critical thinking to solve problems Tech savvy and possess a capability to quickly learn new applications Ability to maintain composure and compassion while addressing a high volume of competing tasks Comfortable with ambiguity and open to collaborative environments Microsoft Word, Excel, Typing/Data Entry



License and Certifications



Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Compliance, Front End, Data Entry, EMR, Law, Legal, Technology, Administrative, Healthcare

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