Claim Auditor I-Health Plan

Location:

Calmont Operations Building

Department:

Reimbursement Analysis

Shift:

First Shift (United States of America)

Standard Weekly Hours:

40

Summary:

The individual in this position performs all job functions in accordance with HIPPA and security rules as it relates to protected health information and has a thorough understanding of claims life cycle.

Additional Information:

The Claim Auditor I is responsible for auditing behavioral and medical claims and ensuring quality metrics are met by conducting post claims reviews on posted claims for Texas Medicaid and CHIP programs. The Claim Auditor I is responsible for auditing a set claim sampling on a monthly basis of routine to moderate complexity which includes paper and electronic claims submission. The Claim Auditor I ensures that claims payment integrity aligns with regulatory standards, timelines, business policy, provider and HHSC contracts, appropriate coding and system configuration. Audit reports may include UB-1450 and HCFA CMS 1500 claim forms not limited to behavioral health, physician, Institutions for Mental Disease, hospital outpatient and inpatient, and long term services and support claims.

• Associates degree required or a minimum of 5 years of claims/audit experience which includes experience with federal programs (Medicaid, CHIP) or in a health plan/payor environment preferred.
• 7-10 years of medical claims processing, claim adjudication, coordination of benefit plan, medical terminology and coding.
• Must have strong organizational skills, problem solving and decision-making skills.
• Advanced knowledge of claim adjudication and benefit plan application for Medicaid and CHIP programs.
• Microsoft Office skills including Word, Excel and Access.
• Excellent customer service skills with ability to explain complicated benefit issues to staff and providers.