Position Summary: Under general supervision, investigate claims liability and determine the extent of liability on a submitted claim for a specific individual. Accurately process the claim according to the policies or contracts that exist, within the departmental time frames and standards, and establish reserves for claim liability.
Relying on experience and judgment, the Specific Claims Auditor is responsible for accomplishing the following assignments. These assignments are broad in nature and work can be difficult.
- Review and interpret employer plans of health coverage and excess insurance policy to individual claims.
- Audit submitted claim documents for sufficient data, verify that benefits were paid correctly and in accordance with appropriate plans and policies, and determine liability
- Communicates in writing and verbally with TPA/client as needed to resolve claim processing issues.
- Set claims reserves and adjusts as needed. Keep the reserves current.
- Authorize checks for amount of liability and communicate to TPA/client reasons for any amounts not covered by excess policy.
- Refer large dollar claims and trigger diagnosis to preliminary claims and case management departments.
- Develop work plans, establish timelines, and set goals for assigned work.
- Meet commitments on deadlines.
- Review activities, results, and recommendations with management and clients as appropriate.
- Drive improvement in existing business processes.
- Perform work thoroughly in a cost efficient manner and at a high productivity level.
Business Controls and Policies
- Comply with all corporate policies and procedures.
- Report any breakdown in controls to management.
- Conduct all activities in a safe manner.
- No people management responsibility but may provide guidance to less experienced employees
Position Knowledge, Skills, and Requirements:
- Associate’s degree in Business Administration or a related field or the equivalent education and/or experience
- Minimum of five years of relevant and progressive professional experience
- Possess and have ability to apply broad knowledge of principles, practices, and procedures
- Strong medical knowledge including ICD, CPT, medical terminology, COBRA, and HIPPA
- Ability to read and interpret documents such as Plan of benefits, claim reports, and procedural manuals
- Excellent written and verbal communications skills with an emphasis on confidentiality, tact, and diplomacy
- Exceptional organizational and analytical skills; demonstrated ability to manage multiple tasks simultaneously
- Knowledgeable of industry changes, legal updates and technical developments related to applicable area of the Company’s business to proactively respond to changing business environment
- Intermediate proficiency and experience using Microsoft Office Package (Excel, Access, PowerPoint, Word)