Clever Care Health Plan is Hiring a Claims Payment and Recovery Auditor Near Huntington, CA
Job DetailsJob Location Huntington Beach Office - Huntington Beach, CA Position Type Full Time DescriptionWage Range: $65,000.00/yr - $75,000.00/yr About Clever Care Health PlanClever Care Health Plan is a Medicare Advantage health plan currently serving Medicare beneficiaries in Southern California. Our employees are passionate in providing best services to our members and healthcare providers. We deliver on our commitment to our members’ health and well-being by offering plans that connect the benefits of Eastern and Western medicine. To learn more, please visit CleverCareHealthPlan.com. Job SummaryThe Claims Payment and Recovery Auditor is responsible for analyzing payments, reviewing detailed paid claims reports, eligibility reports, etc. to ensure claims are adjudicated in a consistent and accurate manner. This Auditor will work closely with the Claims Department to report any findings, identify corrective actions including recommendations for training, development of job aids, system configuration issues, and changes to payment process workflows. The auditor will ensure recovery actions are initiated and funds recovered in a timely manner. This position is responsible for reviewing, auditing, and repricing medical facility and professional claims for accuracy and compliance with CMS and industry standards, contractual language, and plan benefits. Functions & Job Responsibilities
Utilizing a strong understanding of Medicare guidelines review professional and institutional claims to ensure payment accuracy in accordance with CMS guidelines, plan benefits, and provider contracts.
Identify claims requiring reprocessing prior to claims payment. Track processing issues and identify solutions enhances processing in order to achieve greater payment accuracy.
Apply CMS CCI and other Claims edits to ensure that payment is made in accordance with applicable Medicare reimbursement methodologies, LCD, NCD and other payment guidelines related to established plan benefits defined in the member EOC\.
Assist with the reprocessing or repricing of claims to maintain/comply with provider contracts and plan benefit documentation
Determine accurate payment criteria for clearing pending claims based on defined policy and procedures and system configuration.
Identify claim(s) with inaccurate data or claims that require review by appropriate team members
Develop training courses and job aids to improve payment accuracy.
Assist with documentation and follow up activities to document, and pursue recovery of funds paid in error, including reporting of outstanding balances and funds recovered.
Maintain productivity goals, quality standards and aging timeframes
Contribute positively as a team player
Comply with all departmental and company policy and procedures
Research unclear and unusual claims requiring system configuration changes.
Other duties assigned
(See LinkedIn) () QualificationsQualificationsEducation & Experience:
Bachelor’s degree. Will consider senior level experience in lieu of Bachelor’s degree
Four (4) years’ experience within a healthcare claims payment/auditing environment processing Medicare claims; and
Three (3) years as a healthcare payor (claims processor for both institutional and Professional claims)
Experience in insurance claims payment or managed care environment preferred
Skills:
Experience in health plan operations and an understanding of insurance claims processing desired
An understanding of provider reimbursement practices including capitation, sub-capitation, case rates, global rates, per diems, percentage discounts, usual and customary fee schedules, RVU and RBRVS-based fee schedules, purchased repriced network, and health plan specific schedules
Knowledge of CPT, ICD10, HCPCS or other coding structures are required.
Knowledge of UB-04s, CMS 1500 forms, and itemized statements
Knowledge of CMS payment methodologies, use of prices, CCI edits and payment guidance.
Strong overall Microsoft Office skills with an emphasis on Excel skills
Understanding of Dual Eligibility, Medicare, Medicaid and Coordination of Benefits.
Ability to work in a team environment
Integrity and discretion to maintain confidentiality of members, employee and physician data
Knowledge of medical billing and coding
Knowledge of health insurance, HMO and managed care principles
Critical thinking skills and ability to discover and outline systems related issues independently and within a team to provide resolution to work problems
Excellent interpersonal, oral and written communication skills
Strong attention to detail and organization
Able to work independently; strong analytic skills
Flexibility in a fast-paced environment
Physical & Working Environment.Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:
Must be able to travel when needed or required
Must be able to work PST work hours
Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business. Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.