The medical claim auditor position performs daily audits on processed claims that are randomly selected to assure complete, timely and accurate claim payments by HDP processors and technical staff. All claims audits are documented for reporting purposes.
* Review an average of 350+ claims per week that consist of:
* 2% post payment claims for experience claims processors
* Up to 100% pre and post-payment claims for trainees, claims processors learning a new plan or if errors are prevalent in previous audits
* Track errors by processor, type, client, dollars and coding in a specified, consistent format for management and trainer reporting each week and month.
* Attend monthly quality meetings to discuss process improvement for claims processors and our audit department procedures.
* Enter data into the quality access database for consistent weekly, monthly and quarterly management and client reporting.
* Work with the operations staff to:
* Evaluate training needs for claims staff
* Determine needs of other departments in relation to claims staff or benefit plans
* ID systems issues and refer them to the Quality Manager.
* Perform specific audits per the request of clients or HDP staff.
* Perform additional functional audits for areas identified through the organization.
* May include but are not limited to: processing claims, claim system testing, over/under payments and special projects.
* Strong knowledge of claim processing
* Minimum 5 years claim processing experience
* Strong claims technical background
* Proficiency in Microsoft Office (Word, Excel and Access)
* Ability to read and understand a summary plan description (SPD)
* Attention to detail
* Good organizational skills
* Good interpersonal skills and diplomacy
* Quality Oriented
Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity.
Location/Region: Hudson, OH (US - 44236)