Job Abstract

PURPOSE OF POSITION:

The primary purpose of the Auditor is to audit samples of claims processed and service calls received to determine the accuracy of individual claims processors, service reps and the Claims/Service departments both pre and post disbursement. Other functions may include auditing any aspect of insurance operations including but not limited to pharmacy claims, member eligibility, vendor production of the EOBs, coordination of Reinsurance claims at closings, organization of ID card reviews, plan set up in the processing system to ensure that benefits will be paid accurately as indicated on the checklist and schedule of benefits, management of special closings, analysis of claims payment trends and operational audits as necessary. Auditors will be assigned specific responsibilities as listed above based on expertise, knowledge, and experience.

RESPONSIBILITIES & EXPECTATIONS:

* Quality Review:

o Audits the appropriate number of claims, calls, and EOBs

o Checks for completeness and accuracy of benefit calculation of claims processed and service calls

o Release high dollar claims

* Problem Management and Initiative:

o Maintains accurate work records and reports of analysis trends

o Submits suggestions to improve or revise policies, procedures, or operations

* Process Improvement: Continuously reviews, recommends and implements improvement steps, as needed or directed.

* Seeks supervisory guidance/approval as appropriate.

* Portrays professional image: follows dress code; communicates with internal and external customers in a professional manner, including appropriate verbal and written grammar.

* Promotes and demonstrates professional standards to enhance the development of the department.

* Practices ethical conduct.

* Meets acceptable attendance and punctuality expectations (excluding FMLA)

The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified, and shall not be considered as a detailed description of all the work requirements that may be inherent to this position.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.

QUALIFICATIONS:

* Possess a strong claims background.

* High school education with at least 2 years of college or 3 years work experience in the claims processing field.

* Must understand ICD 10 coding and medical terminology.

* Strong written and verbal communication skills.

* Skilled at Microsoft Office, including Word, Excel, Outlook and Power Point

* Ability to type at least 40wpm with accuracy.

WORKING CONDITIONS:

* Hours of operation, shifts as assigned. Occasional overtime, on-call, off-shifts (evenings and/or weekends) scheduled as necessary. Willing to work for others as needed (vacations, sick time, etc.)

* Sitting/standing/moving about intermittently during working hours.

* Subject to frequent interruptions and changes in priority of duties throughout the day.