PRINCIPAL RESPONSIBILITIES:
Under the general supervision of the Manager, Claims and the Claims Supervisor, the principal responsibilities of the Claims Auditor include:
• Audits all Claims Staff production on a daily basis, including the compilation of errors from claims pricing, adjudication, adjustments, phone calls, member bill issues, PM 160s, OTG integration and mail.
• Periodic post audit of claims to determine if the correct adjudication decision was made and the necessary action to alleviate any incorrect decisions.
• Maintain a record of audit results for each staff member. Submits errors back to the proper source to correct and/or adjust issue. Submits a monthly summary report to the Manager, Claims of all departmental errors.
• Prepare a weekly list of common errors to the Manager, Claims and the Claims Supervisor for review at staff meetings.
• Monitor error ratio for incentives.
• Assist in assembling training guidelines and maintain quality improvement for existing staff.
• Reviews, researches and resolves complex claims processing issues.
• Demonstrates continuous effort to improve operations, decrease turnaround times, streamline work processes, and work cooperatively and jointly to provide quality guidance to others in the department.
• Perform duties of Claims Analyst and Processor as needed.
• Other duties and special projects as specified by The Manager, Claims and/or Supervisor.
PERCENT ESSENTIAL FUNCTIONS OF THE JOB
70% Auditing, researching and maintaining the record of audit results.
20% Writing claims guidelines.
10% Weekly error list.
PHYSICAL REQUIREMENTS
• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent walking and standing.
• Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
• Five years in a medical claims processing environment, preferably Managed Care.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
• Ability to correctly interpret claims processing rules, regulations, and procedures to other employees;
• Ability to plan and execute projects independently.
• Ability to communicate effectively, both verbally and in writing.
• Ability to handle multiple projects and balance priorities as well as work for a number of individuals.
Candidates can also mail or fax resumes to:
Alameda Alliance for Health
Attn: Human Resources
1240 South Loop Road
Alameda, CA 94502
510-747-4509
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