Affinity Medical Solutions has an exciting opportunity for a Claims Auditor/Trainer. This position will perform routine and complex audits on claims to identify inaccurate claims adjudication. Will run and audit focused audit reports on a daily basis. Track, research, and document audit findings and determine origin and appropriate resolution. Pre-audit claims selected for health plan audits. Summarize findings and recommendations in reports for feedback to Claims Examiners and Management. Review claims audit results with Director of Claims and Claims Supervisor in order to improve claims processing accuracy. Ensures claims adjudication is in accordance with State, Federal and Health plan regulatory requirements and departmental guidelines. Provide initial claims processing training for Claims Examiners. Provide qualified data for incorporation into training programs, policies and procedures. Assist with functional testing on cross departmental projects.
Desired skills & Experience
We invite you to send your resume and cover letter to firstname.lastname@example.org . Please include "Claims Auditor/Trainer" in the subject line.
- High school graduate, some college desired.
- Knowledge of and working experience with ICD-9, CPT and HCPC coding systems.
- Thorough knowledge of medical terminology, enrollment and membership activities and claim processing procedures/systems.
- Basic understanding of Microsoft Word and Excel applications.
- Seven (7) years prior claims processing experience in an IPA or HMO related setting. Prior experience with claims training and auditing.
- Ability to work independently, organize, and prioritize work assignments.
- Independent decision making skills and demonstrate initiative to resolve issues.
- Excellent oral and written communication skills, great organizational skills and ability to prioritize projects.
- Ability to exercise good judgment and handle a fast paced environment.
- Able to assess and coordinate departmental work flows effectively.
- Ability to process all types of medical claims and interpret authorizations, contracts and physician reimbursement methodologies.
- Ability to train using instructional materials.