Requisition #: M12077
Working Title: Claims Auditor
Business Entity: MDN - Medical Delivery Network
Cost Center # - Cost Center Name: 0853015 - MNS - Managed Care
Job Category: Management/Professional
Job Specialty: Other Professional
Position Type: Regular-F/T
Shift Length: 8hr
Days: Monday - Friday
Shift Type: Day
Job Posting: The Claims Auditor is responsible for ensuring the accuracy of claims processing based on department policies and procedures, CMS and DMHC regulations.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Conducts detail audits for compliance with State, Federal and Health Plan regulatory requirements
2. Conducts pre-and post payment audits on adjudicated claims in compliance with Cedar-Sinai policies, procedures and payment methodologies
3. Documents audit findings and researches errors to determine root cause and makes recommendations for appropriate resolution
4. Provides analysis and prepares recommendations to Management for errors and inconsistences
5. Provides process improvement suggestions to Management
6. Monitors appeals from providers, members and health plans to make sure they are processed accurately and in timely manner.
7. Reviews error trends in processing and keep IS informed for system update.
8. Monitors the daily auditing of processed claims and letters for accuracy.
9. Distribute and monitor multiple projects to make sure deadlines are met.
10. Process all check issues
11. Performs other related duties as assigned or required.
Education Certifications/Licensure Experience Physical Abilities Experience:
Minimum of 5 years of Senior/Lead or Claim Audit experience in a medical claim setting. Four plus years of professional and facility claims processing for Medicare and Commercial products. Must be familiar with provider dispute resolution
Knowledge of claims processing, IDC-10, CPT-4 and HCPC, IDX, Excel, Word, along with CMS and DMHC regulations for compliance. Excellent oral and written communication skills.
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.
While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; sit; and use hands to finger, handle, or feel. The employee is occasionally required to reach with hands and arms. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, depth perception, and ability to adjust focus.
Location/Region: Los Angeles, CA (US)