POSITION SUMMARY:

This position is responsible for maintaining routine auditing functions and providing feedback on departmental activities, to assure compliance with all health plan and regulatory agencies, including CMS, DMHC, and DHS. This position includes the responsibility for routine hospital and professional audits, complex audits on individual or random, training and focused claims to identify exceptions to established claims adjudication requirements for claims processing, payment and procedural accuracy. In addition, this position is responsible to assist with eligibility identify (e.g. COB, ESRD) and Letters of Agreements as required. To maintain in strict confidence, all member, provider and Health Plan information to which Claims Auditing Specialist has access.

EDUCATION AND / OR EXPERIENCE

• High School graduation.
• Possess strong knowledge of CPT, ICD, HCPCS, DRG coding and claims adjudication for hospital and professional claims.
• Knowledge of medical terminology.
• Prefer 5 years previous experience with adjudication all types of claims.
• Basic level proficiency with Microsoft Office applications including Word, Excel, PowerPoint.
  Compensation: $22.50 - $24.5

• Performs routine and complex audits on individual, random, trainee and focused claims to identify exceptions to established claims adjudication requirements for both Pre-EOB and post payment.
• Perform 1st level audit based on reports and run Virtual Examiner Reports prior to each check run.
• Researches claim processing problems and errors to determine their origin and appropriate resolution.
• Researches member activity to identify Coordination of Benefits, Third Party Liability, Out-of-Area and Workers’ Compensation as identified through member admissions, authorization process or claims activity
• Notify management immediately if any report processing deadlines cannot be met.
• Identify, proactively through auditing and internal reporting, negative and positive trends and initiate recommendations for change
• Analyze data processing reports and make necessary corrections or adjustments
• Assist with training of claims adjudication staff as needed
• Assist manager with follow-up on any problems or questions related to the audit results
• Other duties as assigned
  The pay range for this position at commencement of employment is expected to be between $22.50 - $24.50 per hour; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, licensure, skills, and experience.
  The total compensation package for this position may also include other elements, including a sign-on bonus and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered.
  Details of participation in these benefit plans will be provided if an employee receives an offer of employment.
  If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.
  As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.