Claims Quality Assurance Auditor
Salary Range: $72,385 - $108,578
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.
FLSA Status: Non-Exempt
Department: Finance
Reports To: Director, Health Care Economics Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
GENERAL DESCRIPTION OF POSITION
The Claims Quality Assurance Auditor serves as a consultative expert in claims operations supporting the accuracy, consistency, and quality of claims processing by conducting audits of claims processed against established Plan guidelines and protocols specific to claim adjudication, both via manual and auto-adjudication. The auditor is responsible for maintaining a broad knowledge of SCFHP Medi-Cal and Medicare claims processing rules and regulations for use in conducting all claim auditing functions to ensure payment integrity in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, business requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
- Use standardized audit methods to review the quality of claims production on a random sampling basis; record trends and tabulate errors to assure compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, business requirements.
Audit select claims from the pre-payment pool and audit Claims Analysts production on a daily basis. - Conduct targeted audits, including post payment audit for errors and audit historical claims data for systemic or repetitive claims processing errors.
- Monitor and oversee claims reports to verify compliance with claims payment standards established by regulatory and plan policies.
- Provide trending, analysis, and reporting of auditing data relevant information to management; make recommendations.
- Identify and originate necessary system "fixes" with Claims Management as a conduit to initiate a system fix with the IT Department.
- Support claims audit of delegated entities in direct or consultative capacity.
- Support claims appeals and disputes; special projects such as PDR, risk adjustment, contract modeling.
- Train Claims staff in accordance with training guidelines and protocols and provide feedback to Department Manager.
- Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
- Perform other related duties as required or assigned.
REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
- Associate's Degree in Business, Healthcare, or related field, or equivalent experience, training or coursework. (R)
- Minimum of five years of claims processing or claims auditing experience in a health plan. (R)
- Prior experience with managed care plans, Medi-Cal and/or Medicare programs and the working with the underserved populations. (R)
- Knowledge of professional and hospital reimbursement methodologies in Medi-Cal and Medicare and CPT, HCPCS, ICD-10, and ICD 9 codes. (R)
- AAPC Certified Professional Coder. (D)
- Knowledge of medical terminology. (R).
- Understanding of the relationship between the health plans, IPAs, and DOFR. (R)
- Ability to conduct all necessary research, root analysis and trends to accurately identify complex claims issues and to provide guidance to other Claims Analysts for resolution. (R)
- Prior experience conducting internal quality reviews and/or training. (R)
- Ability to lead by example and support the team with complicated issues. (R)
- Proficient in adapting to changing situations and efficiently alternating focus between claims processing and projects/tasks to support Claims Department operations as dictated by business needs. (R)
- Working knowledge of and the ability to efficiently operate all applicable computer software including a working knowledge of computer applications such as Outlook, Word, Excel and claims processing software. (R)
- Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
- Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
- Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
- Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
- Ability to maintain confidentiality. (R)
- Ability to comply with SCFHP's policies and procedures. (R)
- Ability to perform the job safely with respect to others, to property, and to individual safety. (R)
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications. PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
- Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
- Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
- Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
- Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
- Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
- Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels. EOE
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Santa Clara County Health Plan
Nov 02, 2024