The candidate will be responsible for auditing medical claims on a pre-payment basis in accordance with documented Claim Processing Guidelines, Contractual Terms, Plan Payment and Benefit Policies.
They should be able to comprehend and apply provider contract language.
This person is responsible to document audit results in a FOXPRO database for tracking and feedback purposes.
The auditor is responsible to conduct a preliminary root cause analysis for errors found, identify systemic quality issues, and follow-up with internal departments as necessary.
Auditors are responsible to attain and are measured against predetermined Quality and Productivity standards within the department as well as deadlines for completion of all audits and administrative tasks.
3 to 5 years experience with medical claim processing systems and/or procedures
Familiarity with medical coding including CPT, HCPCS, ICD9, and DRG coding
Understanding of electronic claim processes
Demonstrated Analytic Ability
Excellent written and oral communication skills
Excellent organization skills
Hospital (UB04), Physician (CMS1500) Medical Claim Audit, Processing, or Billing Experience
Familiarity with hospital contract language, methodologies and reimbursement policies
Knowledge of industry standard code review editing software
Prior Audit experience helpful
Minimum Educational Requirements:
High School Graduate
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