Claims Auditor

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Claims Auditor is responsible for reviewing claims processed by examiners based on provider and health plan contractual agreements and claims processing guidelines. Follows all internal processes and proce-dures to ensure claims audit activities are handled in accordance with departmental and company policies and procedures. Has excellent knowledge of claims processing rules and Medicare regulatory requirements. Maintains production standards as established by departmental management to meet quality requirements, ensure payment integrity, identify root cause and training opportunities.

Job Duties/Responsibilities:
1. Reviews claims for statistical and payment accuracy.
2. Ensures appropriate payments or denials, and use of adjustment or reason codes are correct.
3. Identifies root cause of errors and work with internal departments for resolution.
4. Reviews claims for fraud, waste or abuse and notifies management of such findings.
5. Updates systems, tracking tools or other documentation methods as needed.
6. Identifies data trends and reports findings to department management with suggestion for resolution and opportunities for process improvement.
7. Prepares and issue audit reports which include audit findings, scores and corrective actions.
8. Monitors completion of corrections.
9. Assists with training of claims examiners based on identified errors.
10. Submits monthly audit reports to management.
11. Fosters good corporate relations by practicing good customer service principles
12. Performs other related duties as assigned.

Job Requirements:

Experience:

• Required: Minimum 3 years of medical claims examining & auditing experience in HMO or IPA/Medical Group setting required, preferably Medicare claims. 2 years of experience using claims processing systems. Minimum 1 year experience working with Provider Dispute and Appeals.

• Preferred: 1 year experience using EZCAP

Education:

• Required: High School Diploma or GED. Bachelor's degree or four years additional experience in lieu of education.

• Preferred: Bachelor’s degree in business or related field.

Training:

• Required: None

• Preferred: None

Specialized Skills:

• Required:

• Ability to use 10 key.
• Proficiency in Microsoft Office programs (Excel, Access, Word), intermediate level.
• Knowledge of medical terminology, standard coding and reference publications, CPT, HCPC, ICD-9, ICD-10, DRG, etc.
• Working knowledge of different claims payment methodologies and claim editing guidelines.
• Familiarity with CMS regulations related to Part C claims.
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.

Licensure:

• Required: None

Essential Physical Functions:

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.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $53,210.00 - $79,815.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/ . If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com .