Claims Auditor-Catastrophic Care Management

Company: Paradigm
Location: Walnut Creek
Posted on: March 28, 2020

Job Description:

Description: This position holds accountability for accurate and timely processing of claims and continuous development of tools to assure the Claims Review Department maintains the highest quality in claims processing.ESSENTIAL RESPONSIBILITIES include the following. Other work-related duties may be assigned.

• Preforms monthly claims audits for claims personnel.
• Maintain accurate records of audit results and identify document patterns of errors made by claims personnel
• Ensure adequate security measures are in place and authority levels and overrides are adhered to
• Ensure that medical review flags are preliminary audit purposes, are in place, reinforced and adhered to. This includes, but is not limited to specific state payment and reporting timelines, preliminary audit on all payments amounting to $10K and over, interim billing processes, prompt pays, specific product handling, etc.
• Perform review of all bills/claims that have been resubmitted and appealed for additional payment
• Serves as back-up for all functions in the processing and examining areas to handle inventory fluctuations or staff shortages.
• Participate in interdepartment meetings in order to support integrated projects.
• Support the claims team in planning, analysis and troubleshooting
• Assist in the development of claims policies and procedures. Ensure that internal operations are in compliance and consistent with new developments, regulations, record keeping and reporting
• Assist the claims manager and Director of Claims in all claims related functions; including training and auditing of current and new staff.
• Other duties and projects as assigned
• Responsible for complying with Paradigm IT security requirement and policies
• Responsible for safeguarding Paradigm or Paradigm related IT passwords.
• Responsible for notifying Paradigm of any IT security incidents per Policy No. 255 Information Security Incident Management.PM19. Requirements: To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Education - AA Degree or equivalent college course work; successful completion of continuing education in insurance, medical terminology/coding, and/or accounting.
  • Experience - 5 years of claims examining or bill review experience. Intermediate computer experience using an MS Word, MS Excel & Outlook required. Typing speed of 60 WPM on data entry. Excellent organizational skills.
  • Knowledge of ICD-10; CPT; Revenue Code; RVS; U&C; Fee Schedule; RBRVS; DRG; HCPCS & other coding schemes.
  • Language Skills - Excellent oral communication skills and phone presence. Ability to effectively present information to providers as well as to employees of the organization.
  • Reasoning Ability - Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret a variety of instructions and deal with abstract and concrete variables.PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.--- Physical Activities - While performing the duties of this job, the employee is regularly required to reach with hands and arms and talk or hear. The employee is frequently required to sit. The employee is required to be mobile.--- Weight Lifted/Force Exerted - The employee's job does not require weight to be lifted or force exerted.--- Vision Requirements - Specific vision abilities required by this job include close vision and the ability to adjust focus.

Keywords: Paradigm, Walnut Creek , Claims Auditor-Catastrophic Care Management, Accounting, Auditing , Walnut Creek, California