Institutional Claims Auditor
NAMM North America Medical Management - Ontario, CA

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Auditing institutional (UB04) claims to ensure accuracy in data entry, payment, and timeliness according to compliance guidelines.

Responsibilities:
Review claims for correct adjudication per established guidelines.

Verify payments and denials.

Advise examiners of needed corrections.

Review daily/weekly reports from IPA's.

Maintain timeliness for check runs on a weekly basis according to CMS and DHMC guidelines.

Review large dollar checks.

Identify areas of needed training.

Qualifications:
Understanding of health plan/industry compliance guidelines.

Working knowledge of the following:
  • UB claim form
  • CPT, ICD-9-Volumes 1, 2, 3 and HCPCS coding
  • Revenue centers associated with billing
  • Hospital, ambulatory surgery center, home health, skilled nursing and dialysis claims
  • Division of Financial Responsibilities
  • Understanding of stop loss
Posses skills in the following areas:
  • Effective written and oral communication
  • Contract interpretation
  • Strong in organization and prioritization
  • Data entry
  • Payment guidelines for Medicare Advantage and Commercial claims
  • Understanding of CCI edits

NAMM North America Medical Management - 16 months ago - save job