Sr. External Claims Auditor

Job Description

The Senior External Claims Auditor performs advanced health plan/DMHC/CMS audits, monitor trends, and perform special analyses. This individual will take the lead to ensure health plan documents are submitted timely, as well as identifying potential issues, and recommending strategies for resolution. Individual is responsible for monitoring audit due dates and analyzing complex project and reports results directly to management. Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.

Responsibilities

• Analyze and audit Health plan claims selections for all health plan/DMHC/CMS audits.
• 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.
• Requires the ability to communicate and analyze Claims processing methodologies according to CMS and DMHC guidelines.
• Apply claim processing experience to audit and analyze all levels of claims processing procedures and workflows.
• Handle complex and urgent audit projects from external provider and internal departments.
• Assist the Recovery Specialist in corresponding with external providers regarding Claims Overpayment requests.
• Accurately document the underpayments and overpayments into the audit database.
• Assist management with analyzing Claim error trends.
• Independently run reports on errors identified for potential error trends and report the results to Claims management and Claims Trainer.
• Build and maintain productive & collaborative intradepartmental relationships with department leads (UM, CM, Pharmacy, Eligibility, Performance Programs, Accounting/ Finance, Compliance, Configuration, Network Management, IT Ops, etc.) to enable effective and timely problem/improvement identification & resolution.
• Identify training needs/ gaps for the team and ensure timely and effective training is imparted to all team members.
  
  

Qualifications

Minimum Education: A High School Diploma or Equivalent required. BS/BA preferred.

Minimum Experience: Previous two (2) years’ experience as Medical Claims Auditor or 7 years previous experience examining Claims required. Strong independent decision-making, influencing and analytical skills. Extensive knowledge of claims processing guidelines including, perspective payment systems, DRG payment systems, comprehensive coding edits, Medicare guidelines, and Medi-Cal guidelines.

"Location-Based Pay Adjustment"

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.