What are the responsibilities and job description for the Claims Auditor position at Verda Healthcare Inc?
Job Description
Job Description
Description : Position Overview
The Claims Auditor ensures incoming claims are processed in accordance with policies, procedures and guidelines, according to Verda Healthcare P&P and contractual agreements; within mandated timeframes; and according to rates as reflected in respective provider contracts. The Claims Auditor will be responsible for pre-payment, post-payment validations and the management of operational reporting, testing and data submissions.
This position reports to the Claims Director in the Claims Department as part of Verda Healthcare, Inc.
Responsibilities :
- Apply Medicare Claims Payment rules and requirements, including the application of National Coverage Decisions, Local Coverage Decisions, and National Correct Coding requirements to claims received for payment.
- Enter claim data accurately and timely, in alignment with departmental production and quality goals
- Ensure claims payments are made within time frames as reflected in contractual agreements
- Maintain a minimum of 98% accuracy at all times
- Perform pre-payment audits and post payment audits to validate both institutional and professional claims for appropriate coding and documentation (including but not limited to MSDRG, DRG, CPT, HCPCS, ICD-10 coding) and validate accurate claim adjudication rules and fee schedules were applied
- Perform pre-payment high dollar claim audits
- Apply policies and procedures to confirm that claims meet criteria for payment and are in compliance with Verda Healthcare contractual guidelines
- Manage difficult, non-routine or escalated claims by using comprehensive research and thorough knowledge of Medicare payment rules
- Identify and manage third party liability (TPL) or coordination of benefits (COB) cases reported by CMS, providers or members. Perform outreach and recovery efforts to Third Party Administrators.
- Coordinate with Finance department for claim payments, voids and refunds. Apply adjustments to the claim payment system as necessary.
- Refer claims for medical management claim review as necessary / applicable.
- Outreach to providers for additional information, including medical records to validate Medicare criteria is met prior to approving a claim for payment.
- Educate providers on billing requirements to reduce claim submission rejections and denials. Educate providers on prior authorization requirements.
- Review and process provider payment disputes according to Verda Healthcare policies and contractual requirements.
- Review and process member requests for reimbursement of claims.
- Create and distribute claim inventory and aging reports as needed. Create ad hoc claim data extracts as needed.
- Create and validate claim reports (Organizational Determinations) prior to submission to CMS to ensure accuracy and completeness of data files
- Assist in the effectuation of overturned appeals made by Verda Healthcare or federal contractor / entity
- Assist in the research and resolution of payment disputes and appeals
- Assist in the creation of case files for the QIO, IRE or other state or federal entity upon request
- Identify and refer to potential fraud and abuse cases to the Compliance Department
- Communicate identified trends to the Claims Department Supervisor for use in development of contracted provider training programs
- Identify opportunities for claims adjudication process improvements
- Perform User Acceptance Testing and support implementation of tools and systems for the Claims Department
- Assist in the training of new staff on claims processing policies, procedures and systems
- Filing and light administrative duties associated with claims processing
- Other duties and responsibilities as may be assigned.
Requirements :
Minimum Qualifications
Professional Competencies
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
Job Type : Full-time
Onsite : 100% onsite
Benefits :Schedule :
Ability to commute / relocate :
PHYSICAL DEMANDS
Regularly sit / walk at a workstation in an office or cubicle setting. Must occasionally lift and / or move up to 25-50 pounds.
