Job Description
Work hours will be 7am-4:30pm PST M-F
Job Summary
Responsible for conducting various audits including, but not limited to; vendor, focal, audit the auditor. Confirm that documentation is clear and concise to ensure accuracy in auditing of critical information on claims ensuring adherence to business and system requirements of customers as it pertains to contracting (benefit and provider), network management, credentialing, prior authorizations, fee schedules, and other business requirements critical to claim accuracy. Maintain audit records, and provide counsel regarding coverage amount and benefit interpretation within the audit process. Provide clear and concise results and comments to leaders about focal audits. Contributes to completion of audits as needed to ensure audits are conducted in a timely fashion and in accordance with audit standards.

Job Duties

• Reviews documentation regarding updates/changes to member enrollment, provider contract, provider demographic information, and/or claim processing guidelines. Evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core processing system (QNXT).
• Conducts focal audits on samples of processed transactions impacted by these updates/changes. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.
• Conducts audits of vendor audits and verifies accuracy of their published outcomes are aligned to the documentation, various sources of truth and being assessed appropriately.
• Clearly documents the focal audit results and makes recommendations as necessary.
• Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 30 days of error issuance.
• Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims. ( Use for claims specific positions only )
• Prepares, tracks and provides audit findings reports according to designated timelines
• Presents audit findings and makes recommendations to management for improvements based on audit results.

Job Qualifications

REQUIRED EDUCATION:

Associate’s Degree or equivalent combination of education and experience

REQUIRED EXPERIENCE, SKILLS & ABILIITIES:

Minimum 2 years as an operational auditor for at least one core operations function
Previous examiner/processing experience in at least one core operations functional area
Strong attention to detail
Knowledge of using Microsoft applications to include; Excel, Word, Outlook, Powerpoint and Teams
Ability to effectively communicate written and verbal
Knowledge of verifying documentation related to updates/changes within claims processing system .
Experience using claims processing system (QNXT).

PREFERRED EDUCATION:

Bachelor’s Degree or equivalent combination of education and experience

PREFERRED EXPERIENCE:

3+ years

• Reviews documentation regarding updates/changes to member enrollment, provider contract, provider demographic information, and/or claim processing guidelines. Evaluates the accuracy of these updates/changes as applied to the appropriate modules within the core processing system (QNXT).
• Conducts focal audits on samples of processed transactions impacted by these updates/changes. Determines that all outcomes are aligned to the original documentation and allow appropriate processing.
• Conducts audits of vendor audits and verifies accuracy of their published outcomes are aligned to the documentation, various sources of truth and being assessed appropriately.
• Clearly documents the focal audit results and makes recommendations as necessary.
• Researches and tracks the status of unresolved errors issued on daily transactional audits and communicates with Core Operations Functional Business Partners to ensure resolution within 30 days of error issuance.
• Evaluates the adjudication of claims using standard principles and state specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims. ( Use for claims specific positions only )
• Prepares, tracks and provides audit findings reports according to designated timelines
• Presents audit findings and makes recommendations to management for improvements based on audit results