Claims Payment and Recovery Auditor is responsible for analyzing payments, review 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.
• Complete other duties and projects as assigned

#LI-Hybrid

Qualifications

Education:

• BS degree preferred - will consider senior level experience in lieu of BS

Experience:

• 4+ years experience within a healthcare claims payment/auditing environment processing Medicare claims; and
• 3+ years as a healthcare payor (claims processor for both institutional and Professional claims)

Skills:

• Experience in health plan operations and an understanding of insurance claims processing desired
• Insurance claims payment or managed care environment preferred

• 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 pricers, 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.

Typical Physical Demands.
Position requires a great amount of driving, sitting and standing. Some standing, stooping, bending or reaching is required. May require lifting up to 15 pounds. Requires manual dexterity sufficient to operate a computer, calculator and telephone. Requires normal range of hearing and vision. Requires the ability to type and file.

Typical Working Conditions.
Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. Work may be stressful at times. May occasionally work some irregular hours.

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.