Sr. Claims Auditor

Job Description

The Senior Claims Auditor is responsible for auditing and monitoring trends, and perform special analyses. This individual will take the lead to ensure accurate and timely adjudication of claims, as well as identifying potential issues, and recommending strategies for resolution. Individual is responsible for reviewing and analyzing complex project and reports results directly to management. Apply claim and/or inquiry processing experience to audit and analyze simple to advanced-level claims processing procedures and workflows

Responsibilities

Job Responsibilities/Duties

• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows. Assigned to handle second level review for high dollar claims prior to release of payment. Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.
• Handle complex and urgent special projects from external provider and internal departments. Assist the PDR department with high profile projects. Must have the ability to accurately make the necessary adjustments for underpayments and review overpayment requests for Claims Recovery Specialist.
• Assist Claims Trainer with analyzing Claim error trends. Also serves as the primary back up for the Trainer in regards to Claims Change Form requests from the Contracting department.
• Analyze and prepare Health plan claims selections for Annual health plan audit. Review samples provider by clerical staff and ensure claims payments are accurate and all documentations required by the health plan auditor are present at the time of audit.
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests. Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.
  
  

Qualifications

QUALIFICATIONS

Minimum Education: Bachelors Degree in related field, preferred.

Minimum Experience: Previous 2 years experience as Medical Claims Auditor or 7 years previous experience examining Medical Claims.

Req. Certification/Licensure: None.

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.