Claims Audit Specialist

This is a fully remote position, open to applicants in California.

📋 Description

• Review claims that have been processed to ensure accuracy in both pre and post-payment stages while managing acceptable levels of aged claims inventory.

• Verify the accuracy of claim payments by checking various elements of the claim form, which includes, but is not limited to, participant eligibility, system configuration, payment correctness or denial validity, provider records, remark codes, pre-authorization requirements, timely filing constraints, claim history, and W9 receipt.

• Keep comprehensive documentation of audit results, detailing decision-making processes, any system configuration or manual processing errors, and financial discrepancies.

• Regularly communicate with the Oversight & Monitoring Manager regarding claims processing mistakes, as well as identify opportunities for quality enhancement and initiate configuration change requests when necessary.

• Process and release high dollar/stop loss claims that exceed $10,000 accurately.

• Participate in annual claims audits to address any deficiencies in the claims system, human errors, or potential fraud, waste, and abuse, ensuring adherence to contractual and regulatory standards.

• Serve as a backup for the Claims team as required.

⛳️ Requirements

• A Bachelor's degree in a relevant field; equivalent professional experience may be considered.

• At least five (5) years of experience in processing, researching, adjusting, and auditing Medicare and Medicaid professional, institutional, and dental health insurance claims.

• Experience in processing and auditing disputes, appeals, and recoveries.

• Proficient in Microsoft Excel.

• Familiarity with the health insurance industry, including knowledge of CPT/HCPCS procedure codes, ICD-10 codes, and pertinent federal and state regulations.

• Experience with CMS and Medi-Cal healthcare claims.

• Strong skills in organization, analysis, communication, and time management.

🏝️ Benefits

• Medical insurance coverage (Medical, Dental, Vision).

• Work/life balance - We mean it! 17 days of personal time off (PTO), 12 holidays observed annually, and 6 sick days.

• 401K savings plus match.

• Comprehensive compensation package that includes base salary and bonuses.

• Additional benefits!