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.

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.

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